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may result in forfeiture of contractual payments. <br />I hereby affirm under the penalties of perjury that the facts and infotnnation contained in the foregoing bid <br />for public works are true and correct. <br />r Dated this I� TAN N day of PW4444 , 20 2� <br />Contractor/Bidder (Firm) <br />ignature of Contracto Bidder or Its Agent <br />21 A t4 AA t T C.i4 G--L_c..._ — S A L C S <br />Printed Name and Title <br />Subscribed and sworn to before me this day of h,, L�, a- i, 20 Z <br />My Commission Expires �I ��- <br />County of Residence <br />otary Public •'`SE L. S'z�o,,, <br />SIN <br />Commission Number ; <br />704898 N <br />%% NOTARY SEAL, ��W* <br />OF a40, <br />