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, , , , <br /> Legal Status (check one) : <br /> Individual Government entity <br /> Owner of sole proprietorship Nonresident alien individual <br /> Partnership Estate or legal trust <br /> Tax-exempt hospital or Foreign corporation <br /> extended care facility partnership estate or trust <br /> Corporation providing or Other - not-for-profit <br /> billing medical and/or organization: <br /> health care services <br /> Corporation NOT providing or Other: <br /> billing medical and/or <br /> health care services <br /> The Grantee acknowledges that the individual signing below is authorized <br /> to execute this Agreement and that such signature constitutes the <br /> acceptance of this Agreement . <br /> GRANTEE: <br /> City of Decatur <br /> /.f <br /> B / Terry M. Howley, Mayor <br /> Y� <br /> (Signat Print or Type <br /> Attest: � <br /> G ��� `- - / �ei�� City Clerk <br /> STATE �MMERCE AND COMMUNITY AFFAIRS <br /> By. <br /> Pam McDonough, Director Date <br /> Grantee Address : Please indicate any changes below <br /> 1 GARY K ANDERSON PLZ <br /> Decatur, IL 62523-1005 <br /> Auth Signator: Terry Howley <br /> Phone: (217) 424 - 2778 <br /> The following is designated as administrator for the Grantee : <br /> Auth Signator: <br /> Phone : <br /> 05/21/2002 12 : 07 : 33 - 2 - <br />