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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 . 2010034
<br /> for 58th Avenue Roadway Modifications ,
<br /> 2 . This sworn statement is submitted by: Si (�. so Co n ir-c(, c:{iytq
<br /> (Name of entity submitting Statement)
<br /> whose business address is :
<br /> q b 15 Ng o_ r 1 c cw (,_ Road ) Sc j�_ i f-e I , 1/e,rd (�e cLC.� 3 F L '3 =q `i U [C
<br /> 3 . My name is J iI el m a n n
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is o i-i lyo, c
<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 /> XNeither 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 /> 00452-1
<br /> FAPublic Works\ENGINEERING DIVISION PROJECTS\0550 SR60&58th Ave Intersection Improvements (KHA)\Admim\Bid Documents\00452
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