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I hereby a f i rin under the penalties of perjui-y that the facts and information contaffied in the foi-egoing- f+ publicwor are true and correct, <br />e, at, .111 , <br />Contractor/Bidder (Firm) <br />Signatisre of Contractor/Biddei- or Its Agent <br />e <br />Pi-inted Name and Title <br />+1 NSubscribed and sworn to before me this � day of U M r?0 <br />My Commission Expires 10 <br />� '� <br />Nu#ary Public <br />County of Residence � • � �� <br />L-//VO <br />fit, JOS�,�;� �;Our�ty, State at Indiana <br />KI-11Y J COUR, Notary Public <br />-M.v commissi <br />���m�a��o� Number NP0729667 01) ExPirers Or-.tober 29, 2028 <br />26 <br />