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1360 SW 01d Dixie Hwy Suite 106
<br /> SECTION 00452 Vero Beach , FL 32962
<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 /> aCos ©8i
<br /> This sworn statement is submitted with Bid , Proposal or Contract No .4 (tea 1 92 for
<br /> 12th Street Sidewalk from 16th Ave to 11 th PI .
<br /> 1 . This sworn statement is submitted by : ` VtYY'Dty' k 04sec".%qeorcT ilk' 1 nc
<br /> (Name of entity submittinq sworn statement)
<br /> w` fiose business address is : 13 QO Q iD 01 XVE HtAU
<br /> , SLQ i Usp
<br /> WIRD SECroil 34cl Q Z - and
<br /> ( if applicable ) its Federal Employer Identification Number ( FEIN ) is (os o Q zq a4
<br /> 2 . My name is
<br /> (Please print name of in vldual signing )
<br /> and my relationship to the entity named above is �T--Jg ' i' EK3T
<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 /> I . 4 . 1 understand that the relationship with a County Commissioner or County employee
<br /> that 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 /> 00452 - Disclosure of Relationships REV 04-07
<br /> 00452 - 1
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