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ACKNOWLEDGED BY, the City of South Bend, Indiana Board of Public <br />Works, on this day of _ 20—. <br />CITY OF SOUTH BEND, INDIANA. <br />BOARD OF PUBLIC WORKS <br />President <br />Member <br />Member <br />STATE OF INDIANA ) <br />SS; <br />COUNTY OF ) <br />Before ine, the undersigned, a Notary Public, in and for said County and State, personally <br />appeared <br />known to me to be members of the City of South Bend, Indiana Board of Public Works and <br />acknowledged the execution of the foregoing Agreement on behalf of said Board. <br />IN WI'i'NESS WHEREOF, I have hereunto subscribed my namer and axed my official <br />sea] 611 the day of^ , 20—. <br />(SRAL) <br />Notary Public <br />Residing in , Indiana <br />This document was prepared by <br />: 1 affirm, under the penaltles of pet fury that I have taken reasonable care to redact each Social Security <br />number in this document, unless required by law. (name) <br />(Acknowledgement Page of City of South Bend, Indiana Board of Public W6rks) <br />