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CITE' OF SANTA ANA <br />RFP NO- 22-096 <br />ON CALL EMERGENCY ASPHALT & PCC <br />OWNERSHIP AFFIDAVIT <br />STATE OF CALIFORNIA } <br />COUNTY OF ORANGE ) SS. <br />Cl" OF SANTA ANA ) <br />t <br />V'C S U , being duly sworn, deposes and says: <br />❑ INDIVIDUAL That he/she is the party making the foregoing proposal: <br />❑ PAR TNERS= That he/she is a inember of the co -partnership firm designated as: <br />and who has been and is duly vested with the authority to make and execute instruments for the co -partnership <br />by: <br />wbo constitute the other members ofthe co-partnership. <br />CORPORAT[ON That he is of: (flee �s- <br />le' <br />a corporation which is making, the otcgoing proposal: <br />❑JOINT VENTURE That be is of: <br />one of the parties making the foregoing proposal as a joint venture, and the he/she has been and is duly vested <br />with the authority to execute instruments for an on behalf of the parties making said bid who are: <br />that such a bid is genuine and not collusive or sham., and has not in any tuanner sought by collusion to secure any <br />advantage against the City of Santa Ana or any person interested in the proposed contract, for himself or any other <br />person. �. <br />Si ature of CONTRACTOR <br />Subscribed and sworn to before me this day of 20 <br />Signature of officer Administering Oath (Notary Public) <br />A notary public or othat officei6compieting this certi Cart <br />es Doty the identify of the in"clual who signed thR <br />r <br />ment to which this certificate is attached. and netfulness, accuracy, or validity oft t document. <br />$we of California, County of <br />Subscribed and sworn to (or affirmed) before me <br />onfhis7dayof <br />proved to me on the basis of satisfactory evidence <br />to be the person(s) h appeared before me. -' <br />Signature.,(,L�"t G2r <br />COLETTE L. GORDON <br />COMM. #2296433 z <br />Notary Public - California ao <br />z <br />Riverside County <br />1 0— !!y Comm, Expires Aua, 4, 2423 <br />Page 3 of 10 <br />