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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 <br /> entity 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 /> (Date) <br /> STATE OF <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this day of , 20 , by <br /> who is personally known to me or who has produced <br /> as identification . <br /> NOTARY PUBLIC <br /> SIGN : <br /> PRINT : <br /> Notary Public , State at large <br /> My Commission Expires : <br /> (Seal) <br /> UESTIONS OR IN UIRES REGARDING THE MEANING OR <br /> INTERPRETATION OF ANY OF THE PROVISIONS OF THIS RFP MUST BE <br /> DIRECTED TO DIANE BERNARD ® FINANCE DIRECTOR. CONTACT WITH <br /> PERSONNEL OF IRIDIAN RIVER COUNTY OTHER THAN DIANE BERNARDO <br /> FOR PURPOSES OF IN UIRIES REGARDING MEANING OR INTERPRETATION <br /> SHALL BE GROUNDS FOR ELIMINATION . THE COUNTY SHALL NOT BE <br /> RESPONSIBLE FOR ANY REPRESENTATIONS MADE BY ANYONE OTHER <br /> THAN DIANE BERNARDO . <br /> Page 15 <br />