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SECTION 00452 - Sworn Statement under Sect. 105.08 Indian River County Code on
<br /> Disclosure of Relationships
<br /> Dj 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 . 9701 for
<br /> Roadway Improvements to SR AIA and CR 510
<br /> 1 . This sworn statement is submitted by: 1 [Y11D 1 ) 7 D5>;y JT�I Q,
<br /> � ac a ��f e�ity bmittiq� sworn stat�nent�
<br /> h�o,e b}{slness E s is : is [
<br /> rill YiQGI.CK ;S '2.- and
<br /> ( If applicable) Its Federal Employer Identification Number ( FEIN ) is jo5iQTKKQ
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement ) ,
<br /> W ,
<br /> 2 . My name is
<br /> (Please print name 0 individual si Ring)
<br /> and my relationship to the entity named above is DWY)Q,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, 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 /> 1 app les . ]
<br /> J ; 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 /> I 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 /> ) I
<br /> 00452 - 7 00452 - Disclosure of Relationships.doc
<br /> F1Public W orks\Capital Peleds\SR AlA 8 CR 510 Turn Lanes_IRC-9701\13ID DOCUMENTS 2006079\00452 - Disclosure of Relationships.hoc Rev. 05101
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