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SECTION 00452 - SWORN STATEMENT UNDER SECTION 105 . 081 INDIAN RIVER
<br /> COUNTY CODE ON 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 . 9205 for 4th Street
<br /> Widening from U . & 1 to West of Old Dixie (�
<br /> 1 . This sworn statement is submitted by: t�'h �s 1d5bc CQEAt"2L i1U IpC
<br /> (Name of shtity submitting sworn statement) %..J
<br /> whqse busi{n�e�s�s �address is : 13to0 ,CrLo Cxu TX X le kAu 4
<br /> 3gq Ion and
<br /> (if applicable ) its Federal Employer Identification Number ( FEIN ) is 1Q ,'; 4)Q < a4a
<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 ')S 1' n pyo h w b�
<br /> (Please_ print name of Ind dual signing)
<br /> and my relationship to the entity named above is Psi Aon r-
<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 . 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, father4n-law, mother in-
<br /> law, daughter4n4aw, son-in-law, brother-in-law, sister4n-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 /> .z 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 /> 1h 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 /> _. ., _ . . ._.._. . __.._. . .-.� . . . c....e•_ro.+ n villi IAINCONTRACT DOCUMENTSX00452 - Disclosure of Relationshlos.doc Rev. 05MI
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