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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 . 5074 for
<br /> South RO WTP Clearwell Addition , Post Treatment Modifications , FRP Piping Replacement
<br /> ' 1 . This sworn statement is submitted by : WPC Industrial on ract nrG i Ltd .
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is : 11651 Phillips Hwy .
<br /> Jacksonville FL 32256 and
<br /> ' ( if applicable ) its Federal Employer Identification Number ( FEIN ) is 59 . 3463 861 ( If
<br /> the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement . N / A ) .
<br /> ' 2 . My name is Jonathan Belloit
<br /> (Please print name of individual signing ) -
<br /> ' and my relationship to the entity named above is President of General Partner
<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 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-law,
<br /> ' daughter-in-law, son-in -law, brother-in -law, 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 /> XXX 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 /> 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 /> 044572000
<br /> ' 00452 - 1
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