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SECTION 00452 - Sworn Statement under Sect . 105 . 08 Indian River County Code on
<br /> Disclosure of Relationships
<br /> p
<br /> r THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY P
<br /> OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS . PUBLIC;
<br /> This sworn statement is submitted with Bid , No . 2011012 for Quail Creek Subdivision .
<br /> 1 . This sworn statement is submitted b
<br /> I VIM 0 -
<br /> ( Name of entit submitting sworn statement )
<br /> whose Ousiness address is : and
<br /> ( if applicable ) its Federal Employer ldentifi ation Number ( FEIN ) is c 9 .
<br /> r
<br /> 2 . My name is ry vi ' <- ,
<br /> ( Please print name of individual signing ) _
<br /> and my relationship to the entity named above is ��-
<br /> 3 . 1 understand that an " affiliate " as defined in Section 105 . 08 , Indian River County Code ,
<br /> Nmeans :
<br /> The term "affiliate " includes those officers, directors, executives, partners,
<br /> shareholders , employees , members , and agents who are active in the management of
<br /> the entity.
<br /> 4 . 1 understand that the relationship with a County Commissioner or County employee that
<br /> must be disclosed is as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle , aunt first
<br /> cousin , nephew, niece, husband, wife, father-in -law, mother- in -
<br /> law, daughter-in -law, son -in -law, brother-in -law, sister-in -law, step -
<br /> father, stepmother, stepson , stepdaughter, stepbrother, stepsister,
<br /> half brother, half sister, grandparent or grandchild.
<br /> 5 . Based on information and belief , the statement which I have marked below is true in
<br /> relation to the entity submitting this sworn statement . [ Please indicate which statement
<br /> applies . ]
<br /> Neither the entity submitting this sworn statement , nor any officers , directors ,
<br /> executives , partners , shareholders , employees , members , or agents who are active
<br /> q in management of the entity , have any relationships as defined in Section 105 . 08 ,
<br /> Indian River County Code , with any County Commissioner or County employee .
<br /> The entity submitting this sworn statement , or one or more of the officers directors
<br /> executives , partners , shareholders , employees , members , or agents who are active
<br /> I
<br /> n management of the entity have the following relationships with a County
<br /> Commissioner or County employee :
<br /> 00452 - 1 00452 - Disclosure of Relationships . doc
<br /> F . \Engineering\Land Development Permits\Quail Creek PD\Bid - Contract Documents\00452 - Disclosure of Relationships . doc
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