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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 Affidavit assists the <br /> City in making determinations relative to conflict of interests and ot�er laws-if questions contact the City of Decatur Legal <br /> Department at 217/424-2807.) <br /> STATE OF Illinais ) <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. Tele Scan Inc. (Hereinafter"Professional Service Provider"}is a: <br /> Company Name <br /> (Place mark in front of appropriate type of business} <br /> X Corporation(if a Corporation,complete B) <br /> Parmership(if a Partnership,complete G) <br /> Lirr►ited Liability Corporation(if an LLC,complete C) <br /> Individual Proprietorship(if an Individual,complete D) <br /> Professional Service Provider's Federat Tax Identification Number is 37-1289839 <br /> B. CORPORATION <br /> The State of Incorporation is Illinois <br /> Registered Agent of Corporation in illinois: Business Information(If Different from Above}: <br /> John Latshaw <br /> Name Company Address,Principal Office <br /> 6275 E.Route 36 �_ <br /> Address City, State,Zip <br /> Decatur IL 62521 <br /> City, State,Zip Telephone Facsimile <br /> (217)864-2940 <br /> Tele hone Website <br /> G-1 <br />