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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 /> Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> (Signature) <br /> t46V ' � <br /> (Date) <br /> STATE OF dor i d <br /> COUNTY OF vNd t ayN, <br /> The foregoing instrument was acknowledged before me this 2,0 day ofJ,/P U� r , 20.L by <br /> WcI ( t � IM P.5S � (n , wh s personall—y <br /> know to me or who has produced <br /> as identification . <br /> NOTARY PUBLIC <br /> SIGN : <br /> PRINT : <br /> Notary Pu lic , State at large <br /> My Commission Expires : <br /> ( Seal ) <br /> aNotary Public State of Florida <br /> Christy Shushan <br /> My Commission EE017547 <br /> Expires 10121 /2014 <br /> 00452-2 <br /> F : \Public Works\ENGINEERING DIVISION PROJECTS\ 1336-Gifford Senior BallfieldWdmin\bid documents\MasterContract\Contract <br /> Documents\00452 Disclosure of Relationshics . doc <br />