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I Dixie Hwy Suite 10E
<br /> SECTION 00452 - Sworn Statement under Sect . 105 . 08 Indian River C t j APP, 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 /> This sworn statement is submitted with Bid , Proposal or Contract No . 2008074 for Eagle Trace
<br /> Subdivision - Phase II
<br /> 74yeat4 Roae eoeft4ctt4eg, #70e4o
<br /> 1 . This sworn statement is submitted by: 1360 SW Old Dixie Hwy Suite 106 '
<br /> Wen Rparnh Fl U962
<br /> (Name of enti y su ml Ing tworn s a (iment)
<br /> whose business address is :
<br /> and
<br /> ( if applicable ) its Federal Employer Identification Number ( FEIN ) is ( - b2 a
<br /> 2 . My name is1 t � Q
<br /> (Please print na ividua�l sign' g)
<br /> and my relationship to the entity named above is MY
<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 . 1 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 /> a plies . ]
<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 /> 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 /> L
<br /> L
<br /> 00452 - Disclosure of Relationships REV 04-07 . doc
<br /> 00452 - 1
<br /> F :\Engineering\Special Projects\Eagle Trace Phase 2\Contract Documents\Eagle Trace Subdivision Phase 11\00452 - Disclosure of Relationships REV 04-07 .doc
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