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Name of Affiliate Name of County Relationship <br /> or Entit Commissioner or employee <br /> 1 . <br /> 2 . <br /> 3 . <br /> I 4 . <br /> 5 . <br /> I 6 . <br /> 7 . <br /> 8 . <br /> 40 <br /> (signature) <br /> (date) <br /> STATE OF t%-As5tLc , s <br /> COUNTY OF52_aC <br /> Personally appeared before me , the undersigned authority , Kr no ` cj P, k�L. who after <br /> first being sworn by me , affixed his/her signature in the space provided above on this 3 rd day of <br /> 20 02�:. <br /> \r** Auk <br /> Notary Public , State at large <br /> My Conuvydssion Expires : <br /> i <br /> OFFICIAL SEAL END OF SECTION <br /> DEBORAH A. LAMOUREAUX <br /> NOTARY PUBLIC <br /> COMMONWEALTH OF MASSACHUSETTS <br /> My Comm. Expires May 19, 2011 <br /> i <br /> i <br /> i <br /> 044572017 <br /> i00452-2 <br />