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Exhibit G <br /> Exhibit G <br /> PROFESSIONAL SERVICE PROVIDER'S DISCLOSURE AFFIDAVIT <br /> { <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 Douglas <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 Paul' s Machine & Welding Corp. <br /> (Place mark in front of appropriate type of business) <br /> ®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 /> Professional Service Provider's Federal Tax Identification Number is 3 7-Q 8 913 9 2 <br /> B. CORPORATION <br /> The State of Incorporation is Delaware <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Name Edward W. Cler Company Address,Principal Office <br /> President <br /> Address 650 N. Sycamore St City,State,Zip <br /> City, State,Zip Villa Grove, IL 61956 Telephone Facsimile <br /> 217-832-3311 <br /> Telephone 217-832-2541. Website www.paulsmachine.com <br /> G-1 <br />