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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 assists the <br /> City in making determinations relative to conflict of interests and other laws-if questions contact the City of Decatur Legal <br /> 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. 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 Illinois <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.Route 36 <br /> Address City, State,Zip <br /> Decatur,IL 62521 <br /> City, State,Zip Telephone Facsimile <br /> (217)864-2940 <br /> Telephone Website <br /> G-1 <br />