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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 LL--0 XS ) <br /> ss. <br /> COUNTY OF D0UJ LA-S ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I, the undersigned,being duly sworn, do state as follows: <br /> A. (Hereinafter"Professional Service Provider") is a: <br /> Company Name <br /> (Place mark in front of appropriate type of business) d <br /> N,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 /> 081 <br /> Professional Service Provider's Federal Tax Identification Number is 7- iq Z <br /> B. CORPORATION <br /> The State of Incorporation isJr <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> f2 6 CCi rata-r e- <br /> Name uKi.rc� Company Address,Principal Office <br /> Address j� L ` � � ' � � City, State,Zip <br /> 217-83Z-Zi7-85,&- <br /> 3311 <br /> City, State,Zip L /9 S� Telephone Facsimile <br /> Telephone 2/7_ — 2-4k Website <br /> G-1 <br />