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Form 3 <br />Model affidavit fficial interest in claim <br />un t §§ 471.88, subd. 5 and 471.89, subd. 3) <br />STATE OF MINNESOTA <br />COUNTY OF ) <br />I, (Name ofinterested ofTcer), being duly sworn state the following: <br />1) I am (office held 6v interested o tcial) of the city of Minnesota. <br />2) On (dav and dare), the following (YOOds /merchandise /equipment /services) were furnished by <br />(name of business or individual with whom the contract was made) to the city of : (s eci <br />the tune of2oods. merchandise. equipment. or services that were ourchasedl. <br />3) The wntract price for such (AOOds /merchandise /equipment /services) was $_ and their <br />reasonable value was $ <br />4) At the time such (1;oods /merchandise /equipment /serviced were famished to the city, I had the <br />following personal financial interest in this contract: ~ecifv the nature of the personal frnancial <br />interest <br />To the best of my ]mowledge and belief the contract price is as low as, or lower than the price at which <br />the (hoods /merchandise / egrt~ment /services) could be obtained from other sources. <br />I further state that this affidavit constitutes a claim against the city for the contract price, that the claim is <br />just and correct, and that no part of the claim has been paid. <br />Lignature ofinterested o tcia!) <br />Subscribed and sworn to before me this day of month ear . <br />/signature ofnotarv) <br />Omelai Convict of loterest q, <br />