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ERMU CommissionPolicyG.2e1Conflicts of Interest <br />______________________________________________________________________________ <br />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 followinggoods or serviceswere furnished by <br />to ERMU: (specify the type of goods, merchandise, equipmentor <br />services that were purchased). <br />3)The contract price for suchgoods or serviceswas $and their reasonable <br />value was $. <br />4)At the time suchgoods/serviceswere 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 servicescould 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 , 20___. <br />(Notary) <br />GP:3186227 v1 <br />______________________________________________________________________________ <br />Page 5of5 <br />67 <br />