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Exhibit G <br /> j <br /> �t r <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 ILLINOIS_ ) <br /> ss. <br /> COUNTY OF MACON ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned,being duly sworn, do state as follows: <br /> A. Bainbridge,Gee,Milanski and Associates, 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 <br /> B. CORPORATION <br /> The State of Incorporation is Delaware <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Steven G. Bainbridge <br /> Name Company Address, Principal Office <br /> _1670 S. Taylorville Rd. <br /> Address City, State,Zip <br /> Decatur, IL 62521 (217)423-8600 (217)423-8677 <br /> City, State,Zip Telephone Facsimile <br /> 217 423-8600 _www.bgmen ineering.com _ <br /> Telephone Website <br /> G-1 <br />