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7 / 20 / 94 (doc / disclose . doc) Ow
<br />SWORN STATEMENT UNDER SECTION 105.08,
<br />INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY
<br />PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER
<br />OATHS.
<br />1. This sworn statement is submitted with Bid, Proposal or
<br />Contract No .
<br />2. This sworn statement is submitted by
<br />[name or entity
<br />whose business address is
<br />submitting sworn statement ]
<br />and
<br />(if applicable) its Federal Employer Identification Number (FEIN) is
<br />(If the entity has no FEIN,
<br />include the Social Security Number of the individual signing this
<br />sworn statement • )
<br />3. My name is and my
<br />[please print name of individual signing]
<br />relationship to the entity named above is
<br />4. I understand that an "affiliate" as defined in Section 105.08,
<br />Indian River County Code, means
<br />The term "affiliate" includes those officers,
<br />directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in
<br />the management of the entity.
<br />5. I understand that the relationship with a County Commissioner
<br />or County employee that must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister,
<br />uncle, aunt, first cousin, nephew, niece, husband,
<br />wife, father-in-law, mother-in-law, daughter-in-law,
<br />son-in-law, brother-in-law, sister-in-law, step-
<br />father, stepmother, stepson, stepdaughter, step-
<br />brother, stepsister, half brother, half sister,
<br />grandparent or grandchild.
<br />6. Based on information and belief, the statement which I have
<br />marked below is true in relation to the entity submitting this sworn
<br />_ Neither the entity submitting this sworn statement, nor any
<br />officers, directors, executives, partners, shareholders, employees,
<br />members, or agents who are active in management of the entity,
<br />have any relationships as defined in Section 105.08, Indian River
<br />County Code, with any County Commissioner or County employee.
<br />statement. [ Please indicate
<br />which statement applies
<br />. ]
<br />_ Neither the entity submitting this sworn statement, nor any
<br />officers, directors, executives, partners, shareholders, employees,
<br />members, or agents who are active in management of the entity,
<br />have any relationships as defined in Section 105.08, Indian River
<br />County Code, with any County Commissioner or County employee.
<br />
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