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SECTION 00452
<br />SWORN STATEMENT UNDER SECTION 105.08, 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 ADMII\ISTER OATHS.
<br />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No: 2014026
<br />for Indian River County Public Shooting Range — Skeet and Trap Facility Improvements (Phase I)
<br />2. This sworn statement is submitted by: A
<br />Sc? 4-Lree-I.L1
<br />whose business address is:
<br />(Name of entity submitting Statement)
<br />_ 3Mynameis �x�U� J3o¼rb
<br />(Please print name of individual signing)
<br />rdi
<br />and my relationship to the entity named above is A r` --hz+ tc,/\j/L 2
<br />1
<br />Ft 3 2 Y-Ze
<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 />6. Based on information and belief the statement, which I have marked below, is true in relation to the
<br />entity spbmitting this sworn statement: [Please indicate which statement applies.]
<br />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 any
<br />relationships as defined in section 105.08, Indian River County Code, with any County Commissioner
<br />or County employee.
<br />00452-1
<br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1213-IRC Shooting Range -Skeet & Trap Improvemnts & Hunters Train BIdg\Wdmim\bid
<br />documents\Contract Documents\00452 Disclosure of Relationships.doc
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