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SECTION 00452 = 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 . UCP 2208 for
<br /> 16 " Brine Pipeline on 58th Avenues frnm 77rh Srrppr rn 57rh Srraet & East to
<br /> Bent Pines RIB Site
<br /> 1 . This sworn statement is submitted by : _ Tri - sure Corporation
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is : P _ n _ R nsr 6 '; 1 , Aiih11rntja1i3 V1 3 3 R 93
<br /> and
<br /> (if applicable) its Federal Employer Identification Number (FEIN) is 59 - 1498145
<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 Jason Chambers
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is vice President
<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, mother4n-
<br /> law, daughter-in-law, son4n-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 1 have marked below is true in
<br /> relation to the entity submitting this sworn statement. [Please indicate which statement
<br /> applies . ]
<br /> xxxx 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 /> rCommissioner or County employee :
<br /> 00452- 1 00452 - Disclosure of Relationships
<br /> CAMy Dooxnenblproiects102624pecificaUorrs100452 - Disdosum of Relatiom ips.doc Rev. 05/01
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