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�xhlbrt Ci <br /> Exhibit G <br /> CONSULTING ENGINEER'S DISCLOSURE AFFIDAVIT <br /> (NOTE: This Affidavit must be completely filled out and signed by any pariy 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 /> COLJNTY OF Macon ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned,being duly sworn, do state as follows: <br /> A. Blank, Wesselink, Cook&Associates,Inc. (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 37-1090533 <br /> B. CORPORATION <br /> The State of Incorporation is_Illinois <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> Harry M. Cook, Jr. <br /> Name Company Address, Principal Office 'i <br /> 2623 E. Pershin� �I, <br /> Address City, State,Zip <br /> Decatur,Il 62526 <br /> City, State, Zip Telephone Facsimile <br /> 217-428-0973 <br /> Tele hone Website <br /> G-1 <br />