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SECTION 00452
<br /> DISCLOSURE OF RELATIONSHIPS
<br /> THISFORM 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.&WITfor the le Street
<br /> Sidewalk from 43`d Ave to 27" Ave .
<br /> 1 . This sworn statement is submitted by: ��f1L� �Y74 , 4- e� pr� ( � �✓') G
<br /> a f entity s bmitting sworn statement)
<br /> whose business address is:
<br /> and
<br /> (if applicable ) its _ -Fe1deral Employer Identification Number (FEIN ) is 11291
<br /> 2. My name is SlC� fl d � "emil %3
<br /> (Please print name of in 'vidual igning�
<br /> and my relationship to the entity named above is ` �JY�.
<br /> 3 . 1 understand that an "affiliate" as defined in Section 105. 08 , Indian River County Code ,
<br /> means :
<br /> The tern "affiliate " includes those ofFcers, 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 bedisclosed is as. follows:
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br /> cousin, nephew, niece, husband, wife, father-in-law, mothemn-
<br /> law, daughter-in-law, son-in-law, brother-in-law, sister4n4aw,
<br /> stepfather, stepmother, stepson, stepdaughter, stepbrother,
<br /> stepsister, half brother, halfsister, grandparent or grandchild.-
<br /> 5 ,
<br /> randchild:5 . Based on information and belief, the statement which I have marked
<br /> below is true in
<br /> relation to the entity submitting this sworn statement. Please indicate which statement
<br /> applies .
<br /> 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 Commissioner or County employee.
<br /> 00452- 1
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