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SECTION 00452 — SWORN STATEMENT UNDER SECTION 105 . 08 , INDIAN RIVER
<br /> COUNTY CODE , ON DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
<br /> OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS .
<br /> This sworn statement is submitted with Bid , Proposal or Contract No . 9327 for Oslo Road and
<br /> 43 `d Avenue Intersection Improvements
<br /> This sworn statement is submitted by: S,hP. I nct4� aa �'oTnC
<br /> (Name of entity submittin-g wom statement)
<br /> VW
<br /> whose business address is i r1
<br /> 34qS1, and
<br /> ( if applicable ) its Federal Employer Identification Number ( FEIN ) is . -- I ( g q 2 °l89
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement )
<br /> ' 2 . My name is 1
<br /> ( Please print name dividualsig ing )
<br /> and my relationship to the entity named above is i
<br /> 3 . 1 understand that an "affiliate " as defined in Section 105 . 08 , Indian River County Code ,
<br /> ' means :
<br /> The term "affiliate " includes those officers, directors, executives, partners,
<br /> shareholders, employees, members, and agents who are active inthe management
<br /> of the entity.
<br /> 1 4 . 1 understand that the relationship with a County Commissioner or County employee that
<br /> must be disclosed is as follows:
<br /> ' Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br /> cousin, nephew, niece, husband, wife, father-in-law, mother-in -
<br /> law, daughter-in-law, son-in-law, brother-in -law, sister-in -law,
<br /> ' stepfather, stepmother, stepson, stepdaughter, stepbrother,
<br /> stepsister, half brother, half sister, grandparent or grandchild.
<br /> 5 . Based on information and belief, the statement which I have marked below is true in
<br /> relation to the entity submitting this sworn statement. [Please indicate which statement
<br /> appliess j
<br /> V Neither the entity submitting this sworn statement , nor any officers , directors ,
<br /> executives , partners , shareholders , employees , members , or agents who are active in
<br /> management of the entity, have any relationships as defined in Section 105 . 08 , Indian
<br /> River County Code , with any County Commisoloner or County employee .
<br /> The entity submitting this sworn statement , or one or more of the officers , directors ,
<br /> executives , partners , shareholders , employees , members , or agents who are active
<br /> in management of the entity have the following relationships with a County
<br /> Commissioner or County employee :
<br /> Disclosure of Relationships
<br /> '
<br /> 00452 - 1
<br /> FAPublic Works\Capital Projects\0slo . 43rd Avenue\CONTRACT DOCUMENTS\Disdosure of Relalionships.doc Rev . 05/01
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