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SWORN STATEMENT UNDER SECTION 105 . 089 INDIAN RIVER COUNTY CODE ,
<br /> ON DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br /> AUTHORIZED TO ADMINISTER OATHS .
<br /> 1 . This sworn statement MUST be submitted with Bid, Proposal or Contract No . 2012033
<br /> for 6th Avenue S W Culvert Replacement North of 23rd Street S . W .
<br /> 2 . This sworn statement is submitted by : 1 m b_�V D S
<br /> t, V1 11 i Q t
<br /> (Name of entity submitting Statement)
<br /> whose business address is : 3 0 Lk) [ �� I -L \ (AO
<br /> } �
<br /> I 3 . My name is �� VA
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is l Y2� e 5 �jq -e- VJ
<br /> 4 . I understand that an " affiliate" as defined in Section 105 . 08 , Indian River County Code , means :
<br /> The term " affiliate" includes those officers , directors , executives , partners , shareholders , employees ,
<br /> members , and agents who are active in the management of the entity.
<br /> 5 . I understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew , niece, husband , wife ,
<br /> father-in-law , mother-in-law, daughter- in- law , son-in-law, brother-in-law, sister-in-law , stepfather,
<br /> stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent , or
<br /> grandchild .
<br /> i
<br /> 6 . 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 /> Lo//Neither the entity submitting this sworn statement, nor any officers , directors , executives , partners ,
<br /> �, . ... shareholders , employees , members , or agents who are active in management of the entity, have
<br /> any
<br /> relationships as defined in section 105 . 08 , Indian River County Code , with any County Commissioner
<br /> or County employee .
<br /> The entity submitting this sworn statement, or one or more of the officers , directors ,
<br />executives ,
<br /> partners , shareholders , employees , members , or agents , who are active in management of the entity
<br /> have the following relationships with a County Commissioner or County employee :
<br /> 00452- 1
<br /> FAPublic Works\ENGINEERING DIVISION PROJECTS\ 1136-6th Ave SW—Culvert Replacement N of 23rd St SW\Admim\Contract Documents\00452
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