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SECTION 00452
<br />DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
<br />OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 0t) (AC -c.
<br />This sworn statement is submitted with Bid, Proposal or Contract No.f. for the Vero
<br />Lake Estates Water Main — Phase II.
<br />1. This sworn sworp, statement is submitted by:
<br />(Name of entity submitting swom(atement) s is:
<br />whose business address
<br />'ADO iTMS�C v<t L t ' L lC
<br />ve)--44tv
<br />and405—a@ (If
<br />(if applicable) its Federal Employer Identification Number (FEIN) is
<br />the entity has no FEIN, include the Social Security Number of the individual signing this
<br />sworn statement ).
<br />2. My name is ion -C.)4+4
<br />(Please print name of,indivi ual signing)
<br />and my relationship to the entity named above is 1i1 SJr .Q- r)\
<br />3. l 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. I 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 belief,
<br />swome ement statemen�Please indicate which statement
<br />I have marked below is true in
<br />relation to the entity submitting
<br />a Ties.
<br />Neither the entity submitting this sworn statement, nor any officers, directors,
<br />xecutives, 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 />00452-1
<br />H\Projects\0741\Bidding Contract Specifications\Spec Template\2007\00452\Disclosure of Relationships.doc
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