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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 Affidavit <br /> assists the City in making determinations relative to conflict of interests and other laws-if questions contact the City of <br /> Decatur Legal Department at 217/424-2807.) <br /> STATE OF IL ) <br /> ss. <br /> COUNTY OF MACON ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> 1,the undersigned,being duly sworn, do state as follows: <br /> A. TELE SCAN INC. (Hereinafter"Professional Service Provider")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 /> Professional Service Provider's Federal Tax Identification Number is 37-1289839 <br /> B. CORPORATION <br /> The State of Incorporation is IL <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> JOHN LATSHAW _ <br /> Name Company Address,Principal Office <br /> 6275 E. RT. 36 <br /> Address City, State,Zip <br /> DECATUR,IL 62521 <br /> City, State,Zip Telephone Facsimile <br /> (217)864-2940 tsiunderground.com <br /> -Telephone Website <br /> G-1 <br />