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� � <br /> , , <br /> 'Lega� Status (chec� 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 /> GR�INTEE: <br /> City of Decatur <br /> _'_._._._____� <br /> `-'--�- � Terry M. Howley, Mayor <br /> By: � <br /> (Signat,�'re Print or Type <br /> ATTEST: i 9 � �- ' ;'� � <br /> - � ���� ✓ ,�r" ������ City Clerk <br /> STATE � F OIS DEPARTMENT OF COMMERCE AND COMMUNITY AFFAIRS <br /> BY� � ��'� �� � 1�' 2� <br /> Pam McDonough, D" ector Date <br /> ��f� ���� <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 /> :�uth Signator: <br /> Phone : <br /> 05/21/2002 12 : 07 :33 - 2 - <br />