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Exhibit G <br /> E�ibit G <br /> PR(�FESSIONAL SERVICE PROVIDER'S DISCLOSLIRE AFFIDAVIT <br /> (NOTE: This A�davit must be completely filled out and signed by any party doing business with the City. This <br /> Af�idavit assists the City in making determinations relative ta conflict of interests and other laws-if questians <br /> contact the City of Deeatur Legal Department at 2 i 71424-2807.} <br /> STATE QF } <br /> )ss. <br /> COUNTY QF ) <br /> SECTIUN I. BUSINESS STATUS STATEMENT <br /> I,the undersigned, being duly swarn,do state as follows: <br /> A• {Hereinafter"Prafessional Service Provider")is <br /> a: i <br /> Company 1�1ame <br /> (Place mark in front of appropriate iype of business} <br /> _X_Corporation(if a Carporatian,carnplete B) <br /> Partnership(if a Partnership,complete C) <br /> Limited Liability Corporatian(if an LLC,complete C) <br /> Individual Proprietorship(if an Individual,complete D) <br /> Prafessianafi Service Provider's Federal Tax Identificatian Mumber is 37-12I8974. <br /> B. CURPORATit)N <br /> The State af Incorporation is I]linois <br /> Registered Agent of Corparation in Itlinois: Business Informatian(If Different from Above}: <br /> Name Campany Address, Frincipal dffice <br /> Address City, State,Zip <br /> City, State,Zip Telephone Facsimile <br /> Tele hone Website <br /> G-1 <br />