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<br />COUNTY CODE ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
<br />OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />This sworn statement is submitted with Bid, Proposal or Project No. 0430 for Egret Marsh
<br />Stormwater Park,
<br />ER D
<br />1. This sworn statement is submitted by: �- -k G
<br />whose business address is: jb5 S (Name of entity submitting sworn statement)
<br />(if applicable) its Federal Employer Identification Number (FEIN) is 105 - 1\5 lo: a and
<br />any). (If
<br />2. My name is
<br />(~lease print name of individual signing)
<br />and my relationship to the entity named above ism,
<br />3. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County Code,
<br />means:
<br />The term "affiliate" includes those officers, directors, executives, partners,
<br />shareholders, employees, members, and agents who are active in the management
<br />of the entity.
<br />4. 1 understand that the relationship with a County Commissioner or County employee that
<br />must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br />cousin, nephew, niece, husband, wife, father-in-law, mother-in-
<br />law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, step-
<br />father, stepmother, stepson, stepdaughter, stepbrother, stepsister,
<br />half-brother, half sister, grandparent or grandchild.
<br />5. Based on my best information and belief, the statement which I have marked below is
<br />true in relation to the entity submitting this sworn statement. [Please indicate which
<br />statement applies.)
<br />X Neither the entity submitting this sworn statement, nor any officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in
<br />management.of the entity, have any relationships as defined in Section 105.08, Indian
<br />River County Code, with any County Commissioner or County employee.
<br />The entity submitting this sworn statement, or one or more of the officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active
<br />in management of the entity have the following relationships with a County
<br />Commissioner or County employee:
<br />Last Revised 08/2008 00452-1
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