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Exhibit G <br /> Exhibit G <br /> CONSULTING ENGINEER'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 INDIANA ) <br /> ss. <br /> COUNTY OF MONROE ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned,being duly sworn,do state as follows: <br /> A. INTERA Incorporated (Hereinafter"Consulting Engineer")is a: <br /> Company Name <br /> (Place mark in front 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 /> Individual Proprietorship(if an Individual, complete D) <br /> Consulting Engineer's Federal Tax Identification Number is 74-3010638. <br /> B. CORPORATION <br /> The State of Incorporation is TEXAS <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Registered Agent Solutions Inc. 9600 Great Hills Trail, Suite 300W <br /> Name Company Address,Principal Office <br /> 3000 Professional Drive,Suite A Austin,TX 78759_ <br /> Address City, State,Zip <br /> _,Springfield. IL 62703 (512)425-2000 (512)425-2009 <br /> City, State,Zip Telephone Facsimile <br /> www.intera.com <br /> Telephone Website <br /> G-1 <br />