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Exhibit G <br /> Exhibit G <br /> CONSULTING ENGINEER'S DISCLOSURE AFFIDAVIT I <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 making 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 /> COUNTY OF MACON ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I, the undersigned,being duly sworn,do state as follows: <br /> A. Bainbridae, Gee, Milanski&Associates,Ina (Hereinafter"Consulting Engineer")is a: <br /> Company Name <br /> (Place mark in front of appropriate type of business) <br /> X Corparation(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 3'� - d�g��, 3;�— <br /> B. CORPORATION <br /> The State of Incorporation is DELAWARE <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> H. David Ham 1670 S. Tavlorville Road <br /> Name Company Address,Principal Office <br /> 784 Jacobs Wav Decatur, IL 62521 <br /> Address City, State,Zip <br /> Forsyth, IL 62535 217/423-8600 217/423-8677 <br /> City, State,Zip Telephone Facsimile <br /> 217/423-8600 www.b�men ing eerin .g com <br /> Tele hone Website <br /> G-1 <br />