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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. 2QRRQgt for
<br /> 5"' Street SW / 43rd Avenue Bridge Replacement and Interse
<br /> ction
<br /> _Improvements .
<br /> 1 . This sworn statement is submitted by: �11eof`��U '�-�S arm A 60 1
<br /> Nam f entity su itting sworn statement)
<br /> whose business address is:
<br /> and
<br /> (if applicable) its Federal Employer Identification Number ( FEIN ) isSg �* 164 164
<br /> 2. My name is 'R i C)1 r j , � A,,
<br /> (Please print name of inciNidualhsigning )�
<br /> and my relationship to the entity named above is ��1 P
<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 /> I . 4 . 1 understand that the relationship with a County Commissioner or County employee
<br /> that must be disclosed is as follows :
<br /> Father, mother, son; daughter, brother, sister, - uncle, aunt, first
<br /> cousin, nephew, niece, husband, wife, father4n-law, mother-in-
<br /> law, daughter-fn-law, son-in-law, brother4n-law, sister4n-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 /> applies .
<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 Commissioner or County employee .
<br /> - 00452 - Disclosure of Relationships REV 04-07
<br /> 00452 - 1
<br /> FAEngineering\Capital Projects\0206 5th ST SW & 43rd AVE Bridge Replacement & Roadway improvem�ts\CONTRACT BID\00452 - Disdosure d Ratationships REV 04
<br /> 07.doe
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