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SECTION 00452 - Sworn Statement under Sect. 105 . 08 Indian River County Code on
<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 . 0378 for 26th Street
<br /> Bridge Replacement Project.
<br /> ' 1 . This sworn statement is submitted by: hP .I �'f?�t Q- (� eo ,
<br /> I /� , A � /, (Nam f entity su itti g sworn stateme �
<br /> whose business address is : J.l�l) V
<br /> 3 _ and
<br /> ( if applicable ) its Federal Employer Identification Number ( FEIN ) is
<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
<br /> . -- aMy" Skel fiy�j
<br /> (Please print name o>iiryiividl lift,,ing) l
<br /> and my relationship to the entity named above is 1 P(' e5i
<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 in the management
<br /> of the entity.
<br /> 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 /> ap
<br /> plies .]
<br /> 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 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
<br /> ' in management of the entity have the following relationships with a County
<br /> Commissioner or County employee :
<br /> 00452 - 1 0378-00452 - Disclosure of Relationships
<br /> FAEngineering\Capital Projects\0378-26th Street Brldge\0378-26th Street Bridge CONTRACT DOC10378-00452 - Disclosure of Relattonships.doc Rev. 05101
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