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Affidavit of Official Interest in Claim <br /> (under Minn. Stat. §§ 471.88, subd. 5 and 471.89, subd. 3) <br /> STATE OF MINNESOTA ) <br /> COUNTY OF ) <br /> I, , being duly sworn state the following: <br /> 1) I am the of the Elk River Municipal Utilities. <br /> 2) On , the following goods or services were furnished by <br /> to ERMU: (specify the type of goods, merchandise, equipment or <br /> services that were purchased). <br /> 3) The contract price for such goods or services was $ and their reasonable <br /> value was $ <br /> 4) At the time such goods/services were furnished to ERMU, I had the following personal <br /> financial interest in this contract: (specify the nature of the personal financial interest). <br /> To the best of my knowledge and belief the contract price is as low as, or lower than,the price at <br /> which the goods or services could be obtained from other sources. <br /> I further state that this affidavit constitutes a claim against ERMU for the contract price,that the <br /> claim is just and correct, and that no part of the claim has been paid. <br /> Subscribed and sworn to before me this day of , 2012. <br /> (Notary) <br /> GP:3186227 vl <br /> 114 <br />