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EXHIBIT"C" <br /> DISCLOSURE AFFIDAVIT <br /> Hasselberg, Williams, Grebe, Snodgrass & Birdsall <br /> (NOTE: This Affidavit must be completely filled out and signed by any party doing business with the City. <br /> STATE OF ILLINOIS ) <br /> ss. <br /> COUNTY OF PEORIA ) <br /> SECTION 1. BUSINESS STATUS STATEMENT <br /> 1, the undersigned, being duly sworn, do state as follows: <br /> A. Hasselberg, Williams, Grebe, Snodgrass & Birdsall is a: <br /> (Place mark in front of appropriate type of business) <br /> Corporation (if a Corporation, complete B) <br /> —X Partnership (if a Partnership, complete C) <br /> Limited Liability Corporation (if an LLC, complete C) <br /> Individual Proprietorship (if an Individual, complete D) <br /> Service Provider's Federal Tax Identification Number, or in the case of an individual or sole <br /> proprietorship, Social Security Number: 37-1364537. <br /> B. CORPORATION <br /> The State of lncorporation is <br /> Registered Agent of Corporation in Illinois: Business Information (If Different from Above): <br /> Name Company Address, Principal Office <br /> Address City, State, Zip <br /> City, State, Zip Telephone Facsimile <br /> Telephone Website <br /> 1 <br />