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� �,i - � � <br /> 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 mal:ing 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 /> COIJNTY OF DuPage�,��re �. ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned,being duly sworn,da state as fallows: <br /> A Crawford,Murphy&Tilly,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 370844662 <br /> B. CORPORATION <br /> The State af Incorporation is Delaware <br /> Registered Agent of Corporation in Illinois: Business Informatian(If Different from Above}. I <br /> Michael J Doerfler 2750 W Washington St. '� <br /> Name Company Address,Principal O�ce II <br /> 2750 W Washington St. Springfield,IL 62702 ' <br /> Address City, State,Zip <br /> Springfield,IL 62702 217-787-8050 217-787-4183 <br /> �__�_.___..�__....._....__._......_.._.__. -__----_-------.._-. -------_.__._..----.____.__._��.,__ <br /> City, State,Zip Te(ephone Facsimile <br /> 217-787-8050 www.cmtengr.com <br /> Tele hone Website Address <br /> G-1 <br />