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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 <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 L ) <br /> ss. <br /> COUNTY OF MaCcy--\ ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned,being duly sworn, /do state as follows: <br /> A. Tp 1e. 5co—,n //1C. (Hereinafter"Professional Service Provider")is <br /> a: <br /> Company Name <br /> (Place mark in front of appropriate type of business) <br /> 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 3 7 S-1 JQ L <br /> B. CORPORATION <br /> The State of Incorporation is Y <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Sohn <br /> Name Company Address,Principal Office <br /> 6275 e- Woy-fe .3(,, <br /> Address City,State,Zip <br /> be_C")-c I L a / <br /> City, State,Zip Telephone Facsimile <br /> (41 :2) 901 -,3 fl/0 <br /> Telephone Website <br /> G-1 <br />