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SECTION 00452
<br /> 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 . 2007044 for the Public Supply
<br /> Wells Construction and Testing.
<br /> 1 . This sworn statement is submitted by:
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is : 5 7 �Ifl 7 7 `�
<br /> �� uP r5 t X39 OS and
<br /> kit applicable) its Federal Employer Identification Number (FEIN) is D -3 3 7 7 (If the
<br /> entity has no FEIN, include the Social Security Number of the individual signing this
<br /> sworn statement / 1
<br /> 2 . My nameis � p�rt KOh} MeCe ( -
<br /> (Please print name of individual siKing)
<br /> and my relationship to the entity named above is � rpC �8o -\--
<br /> 3 . I understand that an "affiliate " as defined in Section 105 .08, Indian River County Code, means:
<br /> The term "affiliate " includes those officers, directors, executives, partners, shareholders,
<br /> employees, members, and agents who are active in the management of the entity.
<br /> 4 . I understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed is as follows:
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin,
<br /> nephew, niece, husband, wife, father-in-law, mother-in-law, daughter-in-
<br /> law, son-in-law, brother-in-law, sister-in-law, stepfather, stepmother,
<br /> stepson, stepdaughter, stepbrother, stepsister, halfbrother, half sister,
<br /> grandparent or grandchild.
<br /> 5 . Based on information and belief, the statement which I have marked below is true in relation to the
<br /> entity submitting this sworn statement. Please indicate which statement applies.
<br /> Neither the entity submitting this sworn statement, nor any officers, directors, executives ,
<br /> partners, shareholders, employees, members, or agents who are active in management of the
<br /> entity, have any relationships as defined in Section 105 .08 , Indian River County Code, with any
<br /> County Commissioner 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 in
<br /> management of the entity have the following relationships with a County Commissioner or
<br /> County employee :
<br /> 6706-43015 - 155\2/7/07 00452- 1
<br /> V RB
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