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The entity submitting this swom 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 />1. <br />< of �_....�, Relationship <br />Name of Affiliate Name Coun � y <br />Commissioner or employee <br />or Entity <br />2. <br />3. <br />4. <br />5. <br />6. <br />STATE OF fI r' { <br />COUNTY OF <br />Personally appeared before me, the undersigned authority; y ) , '�.OSrff,") .^ r <br />who a�first being sworn by me, affixed his/her signature in the space provided above ofi this <br />ay of , 20 DP . <br />g , ort <br />Notary Public State at lhr <br />My Commission Expir <br />clef- k Notary Public State of Florida <br />Cheryl Meade Holmes <br />My Commission DD693938 <br />Expires <br />p.\Engineering\Capital Projects\0381 Oslo Road Boat Ramp\0381 Contract Documents and Specifications\00452 Disclosure of <br />Relationships.doc 00452-2 <br />