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(Form approved by the Attorney General) <br /> <br />NON_COLLUSIGN_AFFIDAVIT <br />- - ------ --------- <br />STATE OF INDIANA <br />COUNTY OF ST. JOSEPH ~ - ~ "~ <br />The undersigned, being duly svorn on oath says, that he is the contracting <br />__....._ ... party, or, ,that he is the representative, agent, member, or officer. of the <br />contracting party, that he has not, nor has any other member, representative, <br />agent, or officer of .the .firm, company, corporation or partnership <br />represented by him, directly or indirectly, entered into or offered to <br />enter into any combination, collusion or agreement to receive or-gay, and <br />that he has not received or paid, any sum of money~or other consideration <br />for the execution of the annexedJContract other than that vhich appears on <br />the face of the Contract. <br />.a.~... ... -~r- <br />1~'~/~y ~E~~~~~~~ i9 ~~ <br />Subscribed and scorn to before me this _ da of __________________ <br />.~~~' ~-ace- /~ . 2 ~ -. <br />~~~~ - --------1~- ------- --- <br />Notary Pic <br />ny Commission Expires: <br />. ~ MARY Ate etRD <br />NOTARY G1JS1.fC STATf Cf )I4DtAlIA <br />ST..IOSEPk C01.itTY <br />_____I"IY_C_a'o'1ISS_t0_N EXP. ,lt1LY ~.tao3 _________-_ <br />County of Residence: St Joseph <br />Page 17 <br />