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may result in forfeiture of contractual payments. <br />I hereby affirm under the penalties of peijuiy that the facts and information contained in the foregoing bid <br />for public corks are true and correct. <br />Dated this _ day of 20 a <br />Contrac, r/Bidder (F' °m) <br />ig ature of Contractor/Bidder or It Agent <br />A <br />Printed Marne and Title <br />Subscribed and swam to before me this � -rq tayr of M� t 11 h , 20 2A <br />My Commission Expires bCf 6 bf r <br />0- <br />Notaq Public <br />Caunty of Residence —FU f <br />v J,V ALICIA J MOSS <br />Notary Public <br />a a State Of Ohio <br />My Comm. Expires <br />October 10, 2027 <br />oti o <br />