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<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 ADMINISTER OATHS .
<br /> 1 . This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2013008
<br /> for 66h Avenue Roadwa�Improvements (S .R. 60 to North of 49' Street)
<br /> 2 . This sworn statement is submitted by: Dickerson Florida , Inc .
<br /> II
<br /> (Name of entity submitting Statement)
<br /> whose business address is .
<br /> 3122 North 25th Street , Ft . Pierce , FL 34946
<br /> 3 . My name is Larry T . Dale
<br /> i (Please print name of individual signing)
<br /> and my relationship to the entity named above is President
<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-m-law dau ter-in-law son-in-law brother-in-law sister-in-law, stepfather,stepmother, stepson, stepdaughter, stepbrother,
<br /> 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 /> X Neither the entity submitting this swom 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 /> 00452A
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