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SWORN STATEMENT UNDER SECTION 105 . 08 , INDIAN PAVER COUNTY CODE
<br /> ON DISCLOSURE OF RELATIOIYSHIF5
<br /> :CHIS FORM A "_ UST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br /> AUTHORIZED TO ADMINISTER OATHS .
<br /> i . This svi orn statement MUST be submitted with Bid , Proposal or Contract No . 2012028
<br /> for Ind im River County Fairgrounds Phase 2 Overflow and Vehicular Staging for Events
<br /> of Faire ounds ,
<br /> i .
<br /> This sworn statement is submitted by : MANCIL ' S TRACTOR SERVICE , INC .
<br /> (Name of entity submitting Statement)
<br /> whose rrasiness address is :
<br /> 4551 SE HAMPTON COURT , STUART , FL 34997
<br /> 3 , My nain is DON R . MANCIL , JR .
<br /> (Please print name of individual signing)
<br /> and my relationShip tic) the entity named above is PRESIDENT
<br /> 4 , I under sand that an " affiliate" as defined in Section 105 . 08 , Indian River County Code , means :
<br /> 'The tern ) " affiliate" includes those officers , directors , executives, partners , shareholders , employees ,
<br /> members , and agents who are active in the management of the entity.
<br /> � . I undersrand 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 /> stepmotkier, stepson, stepdaughter, stepbrother, stepsister, half brother , half sister, grandparent , or
<br /> grandchild .
<br /> b . 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 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 Cortil,ty employee .
<br /> The entity submitting this sworn statement, or one or more of the officers , directors , executives
<br />,
<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- ,
<br /> F : %Public Works\ENUINEERING DIVISION PROJECTS\ 1047-2 IRC Fairgrounds Overflow & vehicular Staging Phase 2\Admim\bid
<br /> Anti iments\00452 Disclosure of Relationshios . doc
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