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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 determhudions relative to conflict of inten:sts and other laws-if questions <br /> contact the City of Decatur Legal Deparimerd at 2171424-2807.) <br /> STATE OF Illinois ) <br /> )ss. <br /> COUNTY OF Will } <br /> SECTION 1. BUSINESS STATUS STATEMENT <br /> I,the undersigned,being duly sworn,do sante as follows: <br /> A. JPL Environmental Engineering(Hereinafter "Professional Service Provider") is a: <br /> Company Name <br /> (Place mark infront-of appropriate type of 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 /> Q individual Proprietorship(if an Individual,complete l7) <br /> Professional Service Provider's Federal Tax Identification Number is 27- 1513326. <br /> B. CORPORATION <br /> The State of Incorporation is Illinois <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> JPL Environmental Engineering <br /> Name Company Address,Principal Office <br /> 2672 Barrington Circle <br /> Address City, State,Zip <br /> Naperville, IL 60564 <br /> City, State,Zip Telephone Facsimile <br /> 630-362-4287 <br /> Telephone Website <br /> G-1 <br />