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SWORN STATEMENT UNDER SECTION 105 .089 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. 2010028
<br /> for 80' Street Sidewalk Improvements from U.S . 1 to 6a` Avenue
<br /> 2 . This sworn statement is submitted by: Melvin Bush
<br /> Melvin Bush Construction , Inc
<br /> (N me of entity submitting Statement)
<br /> whose business address is :
<br /> 2748 SW Casella Street , Port St . Lucie , FL 34953
<br /> 3 . My name is Melvin Bush
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is President
<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 Prnployee 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, st.pbrother, 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 /> X 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 /> - 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 /> 004524
<br /> P\Public WorkMENGINEERING DIVISION PROJECTS\074443th St4US1 to 6th AveWdmimlbid docurnentsw744 CONTRACT DOCUMENTS\00452
<br /> Disclosure of Relationships.doc
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