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Docusign Envelope ID: 11FE285C-C406-413F-94B5-A51669BC871F

Address of Business Entity:

Nature of the regulation of the Entity by the Duchesne County (including any licenses, permits, etc.):

Nature of the business which the Entity does or anticipates doing with the Duchesne County:

Nature of the transaction involving the Duchesne County for which you may receive or agree to receive compensation from the Entity for assisting, including a description of the services to be performed and the compensation to be rendered:

DISCLOSURE OF OTHER PERSONAL INTERESTS

Please disclose any other personal interest or investment which creates or has the appearance of creating a conflict between your public duties and your personal interests.

Name of the Business Entity or Person: * (Write NA if not applicable.)

Address of Business Entity or Person:

Principal Activity Engaged in by Entity:

Nature of Investment or Involvement: