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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 /> <br />Subscribed and sworn to before me this day of , 20___. <br /> (Notary) <br />GP:3186227 v1 <br />103 <br />