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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 San�amon � <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned, being duly sworn,do state as follows: � <br /> A. Hanson Professional Services Inc (Hereinafter"Professional Service Provider") is a: <br /> Company Name <br /> (Place mark in front of appropriate type af business) <br /> X 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,compiete D) � <br /> Professional Service Provider's Federal Tax Identification Number is 3 7-08447 1 7 <br /> B. CORPORATION <br /> The Staxe of Incorporation is Delaware <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Harvey B. Stephens 1525 S. Sixth St. <br /> Name Company Address, Priucipal Office <br /> 205 S. 5"'Street, Suite 700 Springfield, IL 62703 � <br /> Address City, State,Zip <br /> Sprin�field,IL 62701 217-788-2450 217-788-2503 <br /> City, Sfate,Zip Telephone Facsirnile , <br /> 217-280-4271 www.hanson-inc.com <br /> Tele hone Website <br /> G-1 <br />