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SECTION 00452
<br />DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED
<br />TO ADMINISTER OATHS.
<br />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2009064 for Brine
<br />Line Conversion W a Potable Water Main — 77th Street
<br />2. This sworn statement is submitted by:
<br />(Name of entity submitting Statement)
<br />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. 1 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,
<br />employees, members, and agents who are active in the management of the entity.
<br />5. 1 understand that the relationship with a County Commissioner or County employee that must
<br />be disclosed as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband,
<br />wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law,
<br />stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
<br />grandparent, or_grandchl_d._
<br />6. Based on information and belief, the statement, which I have marked below, is true in relation
<br />to the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />Neither the entity submitting this sworn statement, nor any officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in management of the
<br />entity, have any relationships as defined in section 105.08, Indian River County Code, with any
<br />County Commissioner or County employee.
<br />00452-1
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