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OF Illllm lll� 11 r IIIW "'I "'1111' �� II: 1° Alii CIO <br />Fbr vondor doing Ill busill mdliivi IlPlocal goverimilnental entily <br />i'imis qmmammsmmmlullrmsilmmm oeip cts dlm u°m es Ilr ado Lo the bap liq 1,11AL 23, 8411h Log,,, Replail Session,, iUMUSEMY <br />Thils quuimalfnourtraaina �s Oam:l i9 filled Ilir aciwi,dare m with haplo 176, Laval Gomimuummrsll^lit Gui IR)y ma wrmammft ,vlmdftm a Pale 1lassiw^mmmu <br />has as O.maualumass asl:ataerttald as clle insd II';ad dsoumsm a md.iludaim-Q valttllln am iraatt dav?s,innwn1W arm¢o¢i and Ilia <br />auaa,rpia mnmsamsa msapuuOramemms uundau° Saamlaav 176,1006(a), <br />By law llad almmnulu°aaununah m wuuast be ttlilad wamll1h the iounds aaduNnistr mumwof ffic V rcW gmenirnmenilat manmillfy not bmmum <br />dluamu the Th daadness day allsu° the dato ttlma naus�usthiii kramawmaes aumslnm�a of lads ffiaa rnquuil a On siamernuent la he <br />Mad dgs,S�srmuan 9 iaampuria.-"i,tt� Laval daaermnmummni dada, <br />A waeradar rorniiMtstan n° llfa,uuialm 11 the mwandes Illaaloamw rngN, avmmmP�ales S'ec iwu� l M 11006, i..uam� W Gamirrinont Cn^udia� in <br />aawiansam Wunder Oft ssdias is s� aamiiva�lamm�masamao <br />� llarmua of veindaanmada has a l'mm.a iriir as a.imamimanship with to a 111 govierviritantall enti g, <br />lI_l....... <br />Chock s das !!it you as 111l6wd an alllh�a. d asimaR aakllaaruj <br />)dalad <br />ramuleUvVdua,mttnrmliihe wnttm Ora msd iala ng auttmarkino later Ura «1l1 usaadryk <br />ache ilea data on raWrh <br />you der mmm�a aware ttllual the II"w'rigilGllaaVlmy Mi�s�id a puaslolaartruall�ma was'iai'amaluiaaa a"a inaccurate.) <br />„� .rerowwmrn rvwmmrvnm.....uw...... ...... •�WWW���...www �, n�.m.., <br />s lkaamma a1 lm lrl damwaw.m mmmmmerliitt aillaa�r� a!Illaamml r�ad°malau los. lalammaai�iall�m ms daimmd dusa�larad. <br />Name al Offic w <br />III as�l'da aaapu amnm la, rrmamul ally, aldam° kvli�ssimress ralalmaasdip ssilll'i, lima local gamma rnmrmamriadlaam"w am a farnily, maemada:m^ of the <br />officer, as described lyd daw~liall°a 176 003(n)(2Xd). iklaam dasam,llaa any laluaild Ilalallamnslllmiip with the luaaud government a'fteill,. <br />damnrdlafa subpaillls A and lli $or each, auad�loadlummiammi or llti rmallaass uelailaa slVdllIx di�asamallmd. dl l:aalu addlllallumai llhadas is lois Frormmm <br />dllk as mmaaassami <br />A, is the IllaCW lk,aversuuuammm olliner or a lagsljy m�rrreormadau sp the aldaau, m�aaaiu�rlumd or ttlka y to m°aaa hre lax* tualtea„ <br />oliher llaara maaaaasIIItrarvairmll, Oamu:.aulnrea„ lmrarmm Hie vendor? <br />1 you„'m..... RIO <br />:3. N the viamada uil rasaliisiamd iiDr, llittaattd la rawrWve taxable lmnaasmisa aml�lmam Pori illiwealu^ument lhvoraa, firrmm or a1Pin duraicl'aa�a <br />althe Illam Ill daaaolrsrrmsmntt all'liaaau nr a l'a.mMy mmmrwam;llum.m of the aduut u° ddllk the lamarcaia;a iacumurma is nor raamapsad lmmaam Rie <br />paW daaamuru1�1IM1am°mtt�M au°i[ftk"a <br />Yes El <br />No <br />Dosaribe each empladluiromaunl aul 1nlsh'iia!:rS relationship thal ll�lue�nmaurrdar named is Seamiaul°m l rmmairdalniswitVPm a arurpmmailall4 or <br />other lauuslina�se amulli�dwith respect to madla�h il"wa laa�ai daaamamsl�evii wnii'irreir samaies as ani offilceii or dilrii or holds an: <br />cipmership reafama�lsl al aina;*ir�aumai ally maaore.. <br />❑ <br />Check lOmus, box lill`tthe aamudar Onas oven the local ganrarllnamenttof i� � hr!. .... m �. aaa all a. iaum`uullk rnuaamllmau l <br />vitt da!u admaaa aaa ar mmur,nm°a dada <br />as demammlll. d irul ;sxAlliilmn 176.003(a)(2)031, axall�ilydiiling g0ts ds�sama ed Oma daatman .ttdd didd am i". <br />1� .......... <br />,..�.......�......�... ......... _�� m .� ......� �..� ...,..__._.._w_. o. .W............... <br />v��a��ro u aamaua,gi .uiu.mllnn s amlmilb a0us rdm�uauuuomwaamtt�all���rmmlmm}p flmrm'a <br />IFaiimvr Iluuv�a° lkla d by lammisa O.Wi„s ittl o-ilamlausmisumu sauvir.(it lPmar Fswamla,tts.as � � Revised ' �Nd 102D'ml'l <br />Page 9 of 25 <br />