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SECTION 00452
<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
<br /> } Bid, Proposal or Contract No . 2012052
<br /> for ® � t
<br /> t
<br /> 2 . This sworn statement is submitted by.
<br /> y �
<br /> (blame of entity submitting Statement)
<br /> whose business address is : 13 6b SO C Lc 1) 0 1- i e, � (o
<br /> 3 . My name is 0 C�
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is ��-te. S (j.
<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 /> u 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-m 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 /> t000 Neither the entity submittin this sworn statement nor an officers directors executives , partners,
<br /> g Y P
<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 /> F \Public Works\ENGINEERING DIVISION PROJECTS\1102-Old Dixie Hwy Swk 8th St to SR 60-tAP\Admim\bid documentsWaster Contract
<br /> Documents\oo452 Disclosure of Relationships.doc
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