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SECTION 00452
<br /> SWORN STATEMENT UNDER SECTION 105 . 08 , 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 . 1341
<br /> - for Historic Dodzertown Room Renovations
<br /> I This sworn statement is submitted by : 04(L A c4u vl j Gu
<br /> (Name of entity submitting Statement)
<br /> whose business address is :
<br /> l ZS LW ( 30 sf A- 2 3 r'lEL 331 fL
<br /> 3 . My name is S UIAlr
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is PrP 4� `f AQ rd r
<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 /> 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 /> 00452-1
<br /> FAPublic Works\ENGINEERING DIVISION PROJECTS\1341 -Historic Dodgertown (fka VB Spons Village) Room Renovations)VadminWd documents\Master Contract Docs\Master Contract
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