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SECTION 00452
<br /> SWORN STATEMENT UNDER SECTION 105 . 08 , INDIAN RIVER COUNTY CODE,
<br /> ON DISCLOSURE OF RELATIONSMI S
<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 . 2011045
<br /> for Old Dixie Highway Sidewalk Improvements from 38 `h Lane to 65t1i Street.
<br /> 2 . This sworn statement is submitted by :
<br /> (Name of entity submitting Statement)
<br /> whose business address is : (030 Cdca Ra .
<br /> Cocoe, � 3212(a
<br /> 3 . My name is �N � L\ P � 1t " 1✓ P
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above isCS.: P�-�iOENW7
<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 />,
<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 /> 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 /> 00452-1
<br /> F:\Public Works\ENGINEER[ NG DIVISION PROJECTS\0845-Old Dixie Hwy Sidewalk US1 _69th (LAP)\Admlm\bid documents\00452 Disclosure of
<br /> Relationshics.doc
<br /> „gam .
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