INVITATION TO BID - City of Champaign

DISCLOSURE AFFIDAVIT(NOTE: This Affidavit must be completely filled out and signed by any party doing business with the City. This Affidavitassists the City in making determinations relative to conflict of interest and other laws.)(Fill in state and county in which affidavit is being signed)STATE OF _______________________ )) ss.COUNTY OF_______________________ )I, the undersigned, being duly sworn, do state as follows:SECTION 1. BUSINESS STATUS STATEMENTA. _______________________ (hereafter "Contractor” or “Vendor") is a:_____ Corporation_____ Partnership_____ Limited Liability Corporation (LLC)_____ Individual or Sole ProprietorshipContractor’s Federal Tax Identification Number, or in the case of an individual or soleproprietorship, Social Security Number: __________________________(If a Corporation, complete B; If a Partnership or LLC, complete C; If an Individual, complete D)B. CORPORATIONThe State of Incorporation is _______________________.Registered Agent of Corporation in Illinois:__________________________________Name__________________________________Address__________________________________City, State, Zip__________________________________TelephoneBusiness Information (If Different from RegisteredAgent):_______________________________________Company Address, Principal Office______________________________________City, State, Zip______________________________________TelephoneFacsimile___________________________________WebsiteThe corporate officers are as follows (list and identify all corporate officers - attach additionalsheets if necessary):President:_______________________________Vice President: __________________________Secretary: ______________________________Form D-6 01/09