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CITY OF SANTA ANA <br />PROPOSAL <br />PROJECT NO. 156830: Pedestrian Countdown Beads and Push Buttons <br />OWNERSHIP AFFIDAVIT <br />STATE OF CALIFORNIA ) <br />COUNTY OF ORANGE }ss: <br />CITY OF SANTA ANA } <br />,being duty sworn, deposes and says: <br />❑INDIVIDUAL That he /she is the party making the foregoing proposal: <br />❑ PARTNERSHIP That he /she Is a member of the cc- partnership firm designated as: <br />and who has been and is duly vested with the authority to make and execute <br />Instruments for the co- partnership by: <br />who constitute the other members of the co-partnership. <br />PCI CORPORATION That he Is of: <br />SIEMENS INDUSTRY, INC. <br />a corporation which is making the foregoing proposal: <br />❑JOINTVENTURE That he is of: <br />one of the parties making the foregoing proposal as a joint venture, and the he /she has <br />been and is duly vested with the authority to execute instruments for an on behalf of <br />the 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 />gnature f_ed erS"i 1J 1`. k(-IDIliter} -qr 4 rwia -° <br />Subscribed and sworn to before me this day of _,/ 20 _ <br />Signature of officer Administering Oath (N9arrPublic) <br />PAC&Ci <br />B P -6 <br />20A -17 <br />