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SECTION 00452 — SWORN STATEMENT UNDER SECTION 1uOoM IMLRAP
<br />;,06 COUNTY CODE. ON DISCLOSURE OF RELATIONSHIPS
<br />r 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 Project No. 0612 for Wabasso Beach
<br />Park Restoration
<br />1. This sworn statement is submitted by: Ocean Gate General Contractors, Inc.
<br />(Name of entity submitting swom statement)
<br />whose business address is: 2854 SE Federal Highway Stuart, FL 34994
<br />and
<br />of applicable) its Federal Employer Identification Number (FEIN) is 651084099 (if
<br />the entity has no FEIN, include the Social Security Number of the individual signing this
<br />sworn statement )•
<br />2. My name is
<br />Mark MacDonald
<br />(Please print name of Individual signing)
<br />and my relationship to the entity named above is Owner / 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 />*4.,.. must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br />cousin, nephew, niece, husband, wife, father4n4aw, mother4n=
<br />law, daughter-in-law, 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 my best information and belief, the statement which 1 have marked below is
<br />~' true in relation to the entity submitting this sworn statement. [Please indicate which
<br />statement 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 />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 />Last Revised 12/2007 00452 - 1 Wabasso Beach Pk, Restoration
<br />FAPublic Works\Cliff SuthanikWabasso Beach ParkW construction Bid Documents\Bid Documents as of 1-9-2008\DIv 0 AS OF 1-
<br />�ir &2008\00452 - Disclosure of Relatonships.doc
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