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(Type or print clearly) See instructions at bottom of page Name and Address of Nonbusiness Entity Name Address City State Zip I I I I Name and Address of Principal Offi cer or Directors Name Address City State Zip I I I I I I I I I I I I List the name and address of each person whose fees, dues, payments or other consideration paid to the nonbusiness entity during either of the prior two calendar years has exceeded $500; or who is obligated to or has agreed to pay fees, dues, payments or other consideration exceeding $500 to such entity during the current year. Name Address City State Zip I I I I I I I I I I I I I I Certifi cation: I hereby certify that the information contained herein is a true, complete, and correct statement in accordance with Section 67-6624, Idaho Code. Signature Title Date STATEMENT BY A NONBUSINESS ENTITY C-6 Rev. 1/15 Submit to: [EMAIL REDACTED] Eagle City Clerk 660 E. Civic Ln. Eagle, ID 83616 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED]