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<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 . 2011023
<br /> for Indian River Blvd. Sidewalk Improvements from 12"' Street to 17 `h Street
<br /> 2 . This sworn statement is submitted by: ( l i 'i U- --it • 0 S e—,
<br /> (Name of entity submitting Statement)
<br /> i whose business address is :
<br /> 3 . My name is
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is
<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 j
<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\0745- Indian River Blvd Sidewalk Imp. Proj 12th_17th St. ( LAP )\Admim\bid documents\00452
<br /> - Disclosure of Relationships REV 04-07 . doc
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