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may result in forfeiture of contractual payments. <br />r** <br />I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing No <br />for public works are true and correct. <br />Dated this J7 to day of Mdre4, 20Z <br />ie��c�San� )a.erwooks <br />Coniractor� id�X—� <br />Signature of Contractor/Bidder or Its Agent <br />lHltS �-�j�IHrl - DiNSra�C Ja�e� <br />Printed Name and Title <br />Subscribed and sworn to before me this � day of <br />My Commission Expires (� I � a`�� Z-� <br />County of Residence �- ���� <br />