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e p � Z <br /> i . ' <br /> Legal Status (check one) : <br /> Individual �Government entity <br /> Owner of sole proprie�orship 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 O�her - 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 I <br /> acceptance of this Agreement . I� <br /> GRANTEE: II <br /> City of D tur for th Decatur Fire Department <br /> By• , <br /> 'L. TERRY M. HOWLEY <br /> (Sign u Print or Type <br /> STATE OF IL OIS DEP T F COMMERCE AND COMMUNITY AFFAIRS <br /> By. �m 1 S- �{ - Pa <br /> Pam McDonough, Direct (� Date <br /> Grantee Address : Please indicate any changes below <br /> for the Decatur Fire Dept <br /> 1415 North Water Street <br /> Decatur, IL 62526-4439 <br /> Chief Exec : Terry Howley <br /> Phone : (217) 424 - 2811 <br /> The following is designated as administrator for the Gr-antee : <br /> Chief Exec : <br /> Phone : <br /> PRE-CERTIFIED - 2 - <br />