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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 <br /> Commissioner or County employee . <br /> 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 /> (Date) <br /> STATE OF <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this day of , 20_5 <br /> by , 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 /> Page 22 of 22 <br />