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CITY OF SANTA ANA <br />PROPOSAL <br />PROJECT NO.: 15-6447 <br />WEST GROVE VALLEY NEIGHBORHOOD WATER MAIN IMPROVEMENTS <br />OWNERSHIP AFFIDAVIT <br />STATE OF GA -L4 -F �.^",4 WISCONSIN) <br />COUNTY OF QR 4P GE DODGE ) SS: <br />CITY OF SANTA <br />A�L4 BROWNSVILLE) <br />1,C—, MEL AE12 <br />— , being duly swom, deposes and says: <br />❑ INDIVIDUAL <br />That he/she is the party making the foregoing proposal: <br />❑ PARTNERSHIP <br />That he/she is a member of the co -partnership from designated as: <br />and who has been and is duly vested with the authority to make and execute instruments <br />for the co -partnership by: <br />who constitute the other members of the cc -partnership. <br />CORPORATION <br />That he is of. <br />Michels Pipeline Construction a division of Michels Corporation <br />a corporation which is making the foregoing proposal: <br />❑ JOINT VENTURE <br />That he is of: <br />one of the parties making the foregoing proposal as a joint ventre, and the he/site has <br />been and is duly vested with the authority to execute instruments for an on behalf of the <br />parties making said bid who are: <br />that such a bid is genuine and not collusive or sham, and has not in any manner sought by <br />collusion to secure any advantage against the City of Santa Ana or any person interested in the <br />proposed contract, for himself or any other person. <br />Signature of Bidder <br />and sworn to before me this > S3 day of 20 0 <br />Signature of officer AdministerinApath (Notary Public) <br />P-6 of P-16 <br />