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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 /> ,61W C>�©
<br /> This sworn statement is submitted with Bid , Proposal or Contract No . 6) for
<br /> 1St Road from 35th Avenue to 32nd Avenue and 10th Court SW from Oslo Road to 7 Street SW
<br /> 1 . This sworn statement is submitted by: c45eS. yi :Irl7 , rV�
<br /> (Name of entibaubrVitring sworn statement)
<br /> whose business address is : _ gC. i . 14172pr� re;,: KEG '. -Silk A# /
<br /> 'applicable)
<br /> C � l GL _3� ! ti- Lt- and
<br /> ( if applicable) its F6deral ployer Identification Number ( FEIN ) is 65ej7-74,, 1/r i
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement 1 ) .
<br /> 2 . My name is
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is _&ntr-rdrG
<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 /> 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, brother-in-law, sister-in -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 /> 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 /> 00452 - Disclosure of Relationships
<br /> 00452 - 1
<br /> F:%EngineeringlPeGtion Paving\0522 1st Rd . from 32nd Ave. to 35th Ave\Bid Documents\00452 - Disclosure of Relationships.doc
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