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SWORN STATEMENT UNDER SECTION 105 . 089 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 . 2012036
<br /> for Oslo Road Phase III Roadway Improvements ( 58th Avenue to 43rd Avenue )
<br /> 2 . This sworn statement is submitted by : � IM D-{tiLvl D S� -e
<br /> (Name of entity submitting Statement)
<br /> whose business address is :
<br /> tS
<br /> 3 . My name is
<br /> (Please print name of individual signing)
<br /> g g)
<br /> and my relationship to the entity named above iso . t vLP
<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 , artners shareholders ,
<br /> members , and agents who are active in the management of the entity , employees,
<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
<br /> 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 /> Iwo shareholders, employees , members , or agents who are active in management of the entity, have
<br /> any
<br /> relationships as defined in section 105 . 08 , Indian River County Code , with any County Commissi
<br /> or County employee . oner
<br /> The entity submitting this sworn statement, or one or more of the officers , directors ,
<br /> 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 /> I'll k 00452- 1
<br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\0517-OSLO ROAD 43rd Ave to 58th Ave-Phase III\Admim\bid documents\00452 Disclosure
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