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I hereby affirm under the penalties of perjury that the facts and information contained in the <br />foregoing bid for public works are true and correct. <br />Dated this day of w <br />Contractor/Bidder (Firm) <br />d sr t.ai?ue <br />Notary r ub! ic, .tote of Indj <br />�i�E': coua.ty Signature of Contractor/BOder or Its Agent <br />SEAL Ge,nm?ssinsi #;umber ,urate Cost n:issiQr, Expirenl !6, 2(028 <br />l Printed Name and Title <br />Subscribed and sworn to before me this �'day of ►,1(t C"Q( 20 ;to <br />My Commission Expires �a O a <br />Notary Publi <br />County of Residence W W k- <br />4 <br />