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<br /> SECTION 00452
<br /> SWORN STATEMENT UNDER SECTION 105 . 08, INDIAN RIVER COUNTY CODE ,
<br /> ] ON DISCLOSURE OF RELATIONSHIPS
<br /> QTHIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br /> AUTHORIZED TO ADMINISTER OATHS .
<br /> I . This sworn statement MUST be submitted withBid, Proposal or Contract No . 2011018
<br /> for Oslo Road (CR 606) Phase II Roadway Widening (43 rd Avenue to I27 1h Avenue)
<br /> This sworn statement is submitted by: i� i e _ kP . f 5a n 0 or I G . � n G
<br /> (Name of entity submitting Statement)
<br /> whose business address is :
<br /> 1 4 )� 6 4 0 r V Lfccl
<br /> 3 . My name is 1 w y T - � d 1 -9
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is I ES I D ,; N I
<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 submitting this sworn statement. [Please indicate which statement applies . ]
<br /> V 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
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