|
T
<br /> L
<br /> SWORN STATEMENT UNDER SECTION 105.087 INDIAN RIVER COUNTY CODE, ON
<br /> DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR
<br /> OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br /> i . This sworn statement is submitted with Bid, Proposal or Contract No. 2008070
<br /> for Moorings Club & Indian River County Seawall Roairs
<br /> ? . This sworn statement is submitted by: , i MMM6JAd / ��`�'(f�l ;_ �►
<br /> (Name of entity submitting Statement)
<br /> whose �ne� s i � (2,s "
<br /> 2,
<br /> La
<br /> 3 . My name is "
<br /> (Please print name of individual si g)
<br /> and my relationship to the entity named above is
<br /> 4 . I understand that an "affiliate" as defined in Section 105 . 08, Indian River County Code,
<br /> means : The term "affiliate" includes those officers, directors, executives, partners,
<br /> shareholders, employees, members, and agents who are active in the management of the
<br /> entity .
<br /> 5 . I understand that the relationship with a County Commissioner or County employee that
<br /> must be disclosed as follows :
<br /> L
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece,
<br /> husband, wife, father-in-law, mother-in law, daughter-in-law, son-in-law, brother-in-law,
<br /> sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half
<br /> 9=
<br /> brother, half sister, grandparent, or grandchild.
<br /> b . 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 /> ✓ either the entity submitting this sworn statement, nor any officers, directors,
<br /> kli executives, partners, shareholders, employees, members, or agents who are active m
<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,
<br /> directors, executives, partners, shareholders, employees, members, or agents, who are
<br /> active in management of the entity have the following relationships with a County
<br /> Commissioner or County employee :
<br /> Page 37 of 55
<br />
|