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SWORN STATEMENT UNDER SECTION 105 . 08 , INDIAN RIVER COUNTY CODE ,,
<br /> ON DISCLOSURE OF RELA TIONSMPS
<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 . 2012011
<br /> for Trans -Florida Greenway Trail (North County Park to Sebastian Crossings Blvd
<br /> This sworn statement is submitted by : , A -C
<br /> (Name of entity submitting Statement)
<br /> whose business address is : �_ t' �� C� IJ �' 1;� t V .t - t ice)
<br /> 3 . My name is — 'Al I ` (> '.;'
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is '. F
<br /> rrr
<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 />,
<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
<br /> the
<br /> entity submitting this sworn statement . [Please indicate which statement applies . ]
<br /> ✓ Neither the entity submitting this sworn statement, nor any officers , directors , executivesarta
<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 ,
<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 /> 00452- 1
<br /> F : \Public Works\ENGINEERING DIVISION PROJECTS\0923A Trans Florida Greenway (At Sebastian River Middle School )\Admim\Contract
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