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SECTION 00452
<br />DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGN TO ADMINISTER OATHS.
<br />D IN THE PRESENCE OF A
<br />PUBLIC
<br />OR OTHER OFFICER. AUTHORIZED
<br />This sworn statement is submitted with Bid, Proposal or Contract No. 2009024 for the Oslo
<br />Road Boat Ramp Repairs. in Indian River Counter. Florida. C.P. # 0381
<br />1. This sworn statement is submitted by: Qe\ ; c - Pose C' - s , ri".: 11
<br />(Name of entity submitting swom statement
<br />whose business address is: (pc tle-C ? —9
<br />and
<br />(if applicable) its Federal Employer Identification Number (FEIN) is 79+0 - 0 i;&9
<br />2. My name is
<br />3---Ronnes J nr' b(S
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is ? reA A C, F 0
<br />3. 1 understand that an "affiliate" as defined in Section ' 105.08, Indian River County Code,
<br />means:artners,
<br />The term "affiliate" includes those officers, directors, executives, p
<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,
<br />stepfather, stepmother, stepson, stepdaughter, stepbrother,
<br />stepsister, half brother, half sister, grandparent or grandchild.
<br />5. Based on information and belief, the worn Smtatement � Please indicate which statement
<br />I have marked below is true in
<br />relation to the entity submitting this s
<br />applies
<br />V Neither the entity submitting this swom 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 />F:\ ngineering\CaPital projects\O381 Oslo Road BoatRamp\0381 Contract Documents and Specifications\O0452 Disclosure of
<br />Relationships.doc 00452-1
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