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may result in forfeiture of contractual payments. <br />I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid <br />for public works are true and correct. <br />Dated this P�� day of �,2�, 20J <br />2-n 4.' 14,1 <&-, A Dn , <br />Contractor) r [Fi <br />Sigdature of Co •actor•/Bid or Its Agent <br />a/ -k Desl.?"- &C4- d" ) <br />Printed Name and Title <br />Subscribed and sworn to before me this 0' day of v , 20 <br />My Commission Expires (( ') V <br />-�l M lu �kmdj-D <br />Notary Public � <br />County of Residence � 4 ))^ �/� 4 <br />Heaven Edwards EHeaven Edwards <br />Notary publie Seal State of India! Notary Pubilc Seal Slate of Indiana <br />Elkhart County Elkhart County <br />Comm,nW Number NPO ?' Commiaaton number>Yp072b7Tp <br />My Commamion Expires 03+ My Commissio Expires 0 3 /1 11742 8 <br />Ate'.I <br />Version 08/25/2021 CONTRACTOR'S BID FOR PUBLIC WORK - 6 <br />