20-00631-00-BT_BLR_12326.pdf

Please wait...

If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.

You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.

For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.

Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

O:\FABOBSQDM\Gen\Document Services\Forms Support\AEM Forms\DOTLOGO2.bmp Affidavit of Illinois Business Office Page of BLR 12326 (Rev. 01/20/23) BLR 12326 (Rev. 01/20/23) I, of being first duly sworn upon oath, state as follows:

1. That I am the of

2. That I have personal knowledge of the facts herein stated.

3. That, if selected under the proposal described above, , will maintain a business office in the State of Illinois, which will be located in County, Illinois.

4. That this business office will serve as the primary place of employment for any persons employed in the construction contemplated by this proposal.

5. That this Affidavit is given as a requirement of state law as provided in Section 30-22(8) of the Illinois Procurement Code.

Notary Public Signed (or subscribed or attested) before me on

Signed (or subscribed or attested) before me on

(SEAL)

, authorized agent(s) of by Instructions BLR 12326 - Page 1 of 1 The instructions should not be included when the form is submitted.

This form shall be used for Local Public Agency (LPA) contract proposals and deliver and install proposals. It must be completed by all bidders and submitted with their bids. This is not to be used for Federally Funded projects. See the Bureau of Local Roads and Streets Manual (BLRS) Chapter 12 for more information.

Local Public Agency Insert the name of the LPA soliciting bids for the project.

County Insert the name of the County in which the LPA is located.

Street Name/Road Name Insert the name of the street/road on which the project is located. For projects that include several streets or routes insert various.

Section Number Insert the section number assigned to this project without dashes.

Name of Affiant Insert the name of the Affiant.

City of Affiant Insert the city of residence of the Affiant.

State of Affiant Insert the State of residence of the Affiant.

Officer or Position Insert the position held by the Affiant.

Bidder Insert the bidder's company name.

Bidder Insert the bidder's company name.

County of Insert the name of the County the Affiant is in.

Signature The Affiant must sign and date here.

Name of Affiant Insert the name of the Affiant (typed or printed).

State Insert the name of the state where the signer(s) personally appeared before the notary public.

County Insert the name of the county where the signer(s) personally appeared before the notary public.

Date Insert the date the notary witnessed the signature(s).

Name Insert the name(s) of the Affiant.

Bidder Insert the bidder's company name.

Notary Signature The Notary must sign and seal here.

Date Commission Expires The Notary must write the date their commission expires here.

Distribution:

Upon completion this document gets inserted into the Formal Contract Proposal (BLR 12200) or the Material Proposal/Deliver and Install Proposal (BLR 12240) and must be submitted with the contractor's bid.

Upon execution of a formal contract this form is to be submitted with the formal contract package to the Department. For a Material/Deliver and Install project this form is to be maintained by the LPA.

11.0.0.20130303.1.892433.887364 Affadavit of Illinois Business Office

BLR 12326