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SWORN STATEMENT , UNDER SECTION 105.0$, INDIAN `RIVER COUNTY CODE,
<br /> ON DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY, PUBLIC OR OTHER OFFICER
<br /> IF
<br /> AUTHORIZED TO ADMINISTER OATHS :
<br /> 1 . This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2013007
<br /> for Indian River Boulevard Resurfacing L41 . Street to . 53`d Street
<br /> 2. This sworn statement IF
<br /> is . submitted b :
<br /> Y ln .b) flT1 - lt' 4
<br /> IV
<br /> (Name of entity submitting ; Statement}
<br /> whose business address is :
<br /> FL
<br /> Sea ZA
<br /> 30 My name is '$ PMA A-Q f +� - r �,- 4►
<br /> (Pleaseprintname of individual signing}
<br /> and my relationship o the entity named above is 1�ICho ?2t . 11PA
<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, brother4n-law, sister-in-law, stepfather,
<br /> stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or
<br /> grandchild.
<br /> 6 sed on information and belief, the statement, which I have marked below, is true in relation to the
<br /> entity ftbmitting this sworn statement. [Please indicate which statement applies.]
<br /> vl 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 /> The entity submitting this sworn statement, or one or more of the officers, directors, 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 /> F:iPublic Works\ENGINEERING DNISION PROJECTS\1131411 Blvd Resurfacing 41st St to 53rd St-SEE PROJ 0927\Admim\Contract
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