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may result in forfeiture of contractual payments. <br />I hereby affirm under the penalties of perjury that the facts and information contained in the foregoing bid <br />for public works are true and correct. <br />Dated this day of <br />Printed Name and Title <br />Subscribed and sworn to before me day of OCT— 20—Lj <br />My Commission Expires (1. ... ........... . . . . . . . . <br />Notary P 't <br />County of Residence <br />�'h,ELLY,AMM LMAG <br />�,PJIY PLJO K, — OFRGAAL. SIEN <br />Statie of in6ana, LaPoNle County <br />C 'i�pires t er26,,2.0]2 <br />Cora (a ctob L <br />Version 4/2/2019 Contractor's Bid for Public Works - 6 <br />