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SECTION 00452
<br /> SWORN STATEMENT UNDER SECTION 105 . 08 , INDIAN RIVER CODE
<br /> ON DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED 1N 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 . UCP #2229 for INDIAN
<br /> RIVER COUNTY DEPARTMENT OF UTILITY SERVICES—OPERATIONS COMPLEX ,
<br /> 1 . This sworn statement is submitted by:
<br /> ( Name of entity submitting sworn s tement)
<br /> whose business address is : . 3 zoo �1j l!� X �
<br /> NJ e tt t t and
<br /> ( if applicable ) its Federal Employer Identification Number ( FEIN ) is (n � - 0b9 0j :V1
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement ) .
<br /> 2 . My name is V`► . l \ �.-_ "3 � c.k •� L
<br /> ( Please print name of individual signing )
<br /> and my relationship to the entity named above is
<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 /> i , of the entity.
<br /> 4 . I 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 /> rutlNeither the entity submitting this sworn statement, nor any officers , directors ,
<br /> exves , 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 /> IRC OPERATIONS COMPLEX 00452 — Disclosure of Relationships
<br /> 00452 - 1
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