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E7chibit G <br /> E�ibzt G <br /> C{�I�SCJLTING ENGINEER'S DISCL�SURE A�FIDAVIT <br /> {I�Tt7TE: This Affidavit must ba completely f�Iled nut and sigued bY�Y P�Y doing b��siness wit6 the City. 'T#�is <br /> Affidavit assists the City in malccing determit�ations relativa to canflict af interests and other laws-if questions <br /> contact the City of Decatur I.cgat DeparE�nent at 217i42M28t37.} <br /> STATE 4F I1linois } <br /> �S5. <br /> G'QUNTY QF'' S&Ilg�on � <br /> SECTI{)�I�. BUS�NESS STATfJ�STATEMF;NT . <br /> I,the ut�dersignec�,being duly sworn,do state as follows: <br /> A. Massie Massie+Associates Inc. (�-Iereina£�er"Cansulting Engis�eer"}is a: <br /> Company N'aane <br /> (P1ace mark in front of appxopriate type of business} <br /> � Corparation(xf a Carporation,complete B) <br /> Partnership(if a Partnership,complete C} <br /> X Limited Liabi.lity Caxporatian{if an LLC,corn�Iete C} <br /> Izzdividual Proprietorsi�ip{if an Individual,complete D) . <br /> Co�zsul�ing Engineer's Federal Tax Identi�icatian Number zs <br /> B, CtJRP(JRATIC7N <br /> The Sfate of T�zaorparation is <br /> Registered Agezxt of Corparation in Illinois: Business Information(�£Aiffez�ent from Abave): <br /> IrTarne Company Address,Principal Office <br /> Atic3ress Ci#y, St�te,Zip <br /> City, State,Zip Telephone Facsi�nile <br /> Tel hone Websi#e <br /> G-1 <br />