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may result in forfeiture of contractual payments_ <br />I hereby affirm under the Penalties of petjumy that the facts and information contained in the foregoing bid <br />for public works are true and correct. <br />Dated this day of VVV . 200 <br />.:::z 1-1 d I N Atut 1 k <br />Contractor/Bi der (F' } <br />Signature of Contractor/Biddpeor its Agent <br />Ark Mtr - fte-.�Jen�- <br />Printed Name and Title <br />Subscribed and sworn to before me this 10 -N. day ofrmcLew.bter , 20 Z'A <br />My Commission Expires r,-S <br />Notary Public <br />County of Residence tD A So S.� <br />ROXANNELAURENEALFOHO <br />"Y �Lm�% Notary Public, Stato of Indiona <br />SEAL " St. Joseph County <br />r'• :. Commission Number NP0741524 <br />My Com 31, 203 <br />`xpires <br />