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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 detenninations 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 Champaign ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned. being duly sworn, do state as follows: <br /> A. Clark Dietz, Inc.(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 37-1212051. <br /> B. CORPORATION OR LLC <br /> The State of Incorporation is Illinois <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Capital Corporate Services,Inc. Clark Dietz, Inc. <br /> Name 125 W. Church Street <br /> 1315 W. Lawrence Avenue Company Address,Principal Office <br /> Address Champaign,IL 61820 <br /> Springfield. IL 62704 City, State,Zip <br /> City, State. Zip <br /> 217.373.8900 217.373.8923 <br /> 800-345-4647 Telephone Facsimile <br /> Telephone <br /> www.cla rkdietz.com__ <br /> Website <br /> G-1 <br />