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, , � . „ , 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. HOMER L. CHASTAIN& ASSOCIATES, LLP (Hereinafter "Consulting Engineer")is a: <br /> Company Name <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 /> � <br /> Consulting Engineer s Federal Tax Identification Number is <br /> B. CORPORATION <br /> The State of Incorporation 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 W ebsite <br /> G-1 <br />