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2013018 Shooting Range Safety Baffle Repair and Replacement <br /> SWORN STATEMENT UNDER SECTION 105 . 08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF <br /> RELATIONSHIPS <br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO <br /> ADMINISTER OATHS. <br /> 1 . This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2013018 for <br /> Shootine Range Safety Baffle Repair and Replacement 1 t PP , <br /> 2 . This sworn statement is submitted by: Aytyy IMI (! &LT(1.LG0cM / )k V4Z (Q &&Ci <br /> ( Name of entity submitting Statement ) <br /> whose business address is : <br /> and its Federal Employer Identification Number ( FEIN ) is 5 (p <br /> 3 . My name is W ilt tc3 A 56/1 U&A <br /> ( Please print name of individual signing) <br /> I <br /> and my relationship to the entity named above is Pas ide ,,�4 - <br /> 4. 1 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 . 1 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 /> Page 12 of 18 <br /> May <br /> (o� Notary Public State of Florida <br /> Christy Shulhan <br /> My Commission EE017547 <br /> Or Expires 10/21/2014 <br /> Page 13 of 18 <br /> 2013018 Shooting Range Safety Baffle Repair and Replacement <br /> Warranty Information Form <br /> MEN <br /> (All Blanks must be filled in and Submitted with your Bid) <br />