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' SECTION 00452
<br /> DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRE S
<br /> ENCE OF A NOTARY PUBLIC
<br /> OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br /> This sworn statement is submitted with Bid , Proposal or Contract No .
<br /> County Water Treatment Plant Wellfield Rehabilitation Phase 11 . for the South
<br /> ' 1 . This sworn statement is submitted by: Layne Christensen Company
<br /> Y
<br /> (Name of entity submitting sworn statement)
<br /> ' whose business address is : 2740 Mine & Mill Road
<br /> Lakeland FL 33801 and
<br /> (if applicable) its Federal Employer Identification Number (FEIN) is 48-0920712 (If the
<br /> ' entity has no FEIN, include the Social Security Number of the individual signing this
<br /> sworn statement
<br /> ' 2 . My name is Doyle Goodman
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is General Manager
<br /> 3 . I understand that an "affiliate " as defined in Section 105 . 08 , Indian River County Code , mean
<br /> The term "affiliate " includes those officers, directors, executives, partners, shareholders,
<br /> ' employees, members, and agents who are active in the management of the entity.
<br /> 4 . 1 understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed is as follows :
<br /> ' Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin,
<br /> nephew, niece, husband, wife, father- in-law, mother- in-law, daughter- in -
<br /> law, son- in-law, brother- in -law, sister- in-law, stepfather, stepmother,
<br /> ' stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
<br /> grandparent or grandchild.
<br /> ' 5 . Based on information and belief, the statement which I have marked below is true in relation to the
<br /> entity submitting this sworn statement . [Please indicate which statement applies . ]
<br /> '
<br /> X Neither the entity submitting this sworn statement, nor any officers , directors, executives ,
<br /> partners , shareholders , employees , members , or agents who are active in management of the
<br /> entity, have any relationships as defined in Section 105 . 08 , Indian River County Code, with any
<br /> ' 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 in
<br /> management of the entity have the following relationships with a County Commissioner or
<br /> County employee :
<br /> 6706-38392\ 8 /20/03 00452 - 1
<br /> VRB
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