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E�chibit 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 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 I1�inois � <br /> )ss. <br /> COUNTY OF McLean ) <br /> SECTION I. BUSINESS STATUS STATEMENT <br /> I,the undersigned, being duly sworn,do state as follows: <br /> A. Farnsworth Group, 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 37-1123236 <br /> B. CORPORATION <br /> The State of Incorporation is Illinois <br /> Registered Agent of Corporation in Illinois: Business Information(If Different from Above): <br /> CT Corporation System <br /> Name Company Address,Principal Office <br /> 208 S. LaSalle St., Suite 8]4 <br /> Address City, State,Zip � <br /> � <br /> i <br /> Chicago,IL 60604-1101 <br /> City, State,Zip Telephone Facsimile ' <br /> i <br /> i <br /> Tele hone Website <br /> � <br /> G-1 <br /> ' <br /> I __-- <br />