Laserfiche WebLink
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 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. Blank, Wesselink,Cook,and Associates(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 Illinois <br /> Registered Agent of Corporation in Illinois: Business Information (If Different from Above): <br /> HgM M Cook Jr. <br /> Name Company Address,Principal Office <br /> 2623 East Pershing Road <br /> Address City, State,Zip <br /> Decatur Il.62526 <br /> City, State,Zip Telephone Facsimile <br /> 217 428-0973 <br /> Telephone Website <br /> G-1 <br />