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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 ADMINISTER OATHS .
<br /> 1 . This sworn statement MUST be submitted with Bid, Proposal or Contract No . 2014015
<br /> for GIFFORD PARK BALLFIELDS GRADING IMPROVEMENTS .
<br /> 2 . This sworn statement is submitted by : SL/I� w \ "A ( &) nS+'y vt, ::k pVA 0�C
<br /> (Name of entity submitting Statement)
<br /> SUMMIT CONSTRUIC710N
<br /> whose business address is : 2837 Flight Safety Drive
<br /> VER© BEACH , FL 32960
<br /> (772 ) 794 - 2029 Fax : (772 ) 794 - 210W
<br /> 3 . My name is yj r l ( At C,\ vy\, E) Sa/\Ww
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is 0"Aww F — t?(LC OJLin+
<br /> 4 . 1 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 . 1 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 /> 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 /> FAPublic Works\ENGINEER [ NG DIVISION PROJECTS\1336-Gifford Senior BallfieidWdmin\bid documents\MasterContract\Contract
<br /> Documents\00452 Disclosure of Relationships . doc
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