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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 . ADO 9 01 9 for
<br /> The Enclave Subdivision ,
<br /> 1 . This sworn statement is submitted by: ! A %t aw,4 s'p,y Ge.) _1., r 0s) C. ,
<br /> (Name of ntity s mitting sworn staent)
<br /> whose business address is : I ] �A_� LAN /� U e
<br /> Allow '� and
<br /> (if applicable) its Federal Empl yer Identification Number ( FEIN ) is
<br /> Rrl '..
<br /> I2 . Mynameis AR .d <k e. ] 7'R tri.
<br /> (Please print name of individual signsgg)
<br /> and my relationship to the entity named above is /�R P,S % r 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 I the management of
<br /> 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, brother4n4aw, sister-in-law, step-
<br /> father, stepmother, stepson, stepdaughter, stepbrother, stepsister,
<br /> 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 /> Neither the entity submitting this sworn statement, nor any officers , directors ,
<br /> executives , partners , shareholders, employees , members , or agents who are active
<br /> in management of the entity, have any relationships as defined in Section 105 . 08 ,
<br /> Indian 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 - Disclosure of Relationships REV 04-07.doc
<br /> 00452 - 1
<br /> FAEnWnmdna%SpecW Proleds\Endave subdMslonlconbzd Document\Contract Document\The Endave.dadOD452 - Diadosure of Relationships REV 04-07.doc
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