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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. 2QRRQg4 for
<br />5"' Street SW / 43rd Avenue Bridge Replacement and Intersection Improvements.
<br />1.
<br />2.
<br />3
<br />This sworn statement is submitted by:
<br />entity
<br />whose business address is:
<br />(if applicable) its Federal Employer Identification Number (FEIN) is
<br />My name is � % t)1� (j►l'� +�
<br />(Please print name of i
<br />and my relationship to the entity named above is
<br />signing)
<br />sworn statement)
<br />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 />F:\Engineering\Capital Projects\0206 5th ST SW & 43rd AVE Bridge Replacement & Roadway Improvements\CONTRACT BID\00452 - Disclosure of Relationships REV 04
<br />07.doe
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