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Exhibit G <br /> Exhibit G <br /> PROFESSIONAL SERVICE PROVIDER'S DISCLOSURE AFFIDAVIT <br /> (NOTE: This Affidavit must be completely filled out and signed by any party doing business with the City. This <br /> Affidavit assists the City in making determinations relative to conflict of interests and other laws-if questions <br /> contact the City of Decatur Legal Department at 217/424-2807.) <br /> STATE OF Illinois ) <br /> ss. <br /> COUNTY OF Sangamon ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned, being duly sworn,do state as follows: <br /> A. Crawford,Murphy&Tilly, Inc.(Hereinafter"Professional Service Provider")is a: <br /> Company Name <br /> (Place mark in front of appropriate type of business) <br /> ® Corporation(if a Corporation, complete B) <br /> ❑ Partnership(if a Partnership, complete C) <br /> ❑Limited Liability Corporation(if an LLC,complete C) <br /> ❑ Individual Proprietorship(if an Individual,complete D) <br /> Professional Service Provider's Federal Tax Identification Number is <br /> B. CORPORATION <br /> The State of Incorporation is Delaware <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Michael J. Doerfler 2750 West Washington Street <br /> Name Company Address,Principal Office <br /> 2750 West Washington Street Springfield, IL 62702 <br /> Address City, State,Zip <br /> Springfield, IL 62702 (217)787-8050 <br /> City, State,Zip Telephone Facsimile <br /> (217)787-8050 www.cmtengr.com <br /> Telephone Website <br /> G-1 <br />