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SECTION 00452
<br />DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR
<br />OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />This sworn statement is submitted with Hid, Proposal or Contract No. Bid No. 2009046 -- UCP #
<br />2830 for the 16" Reuse Water Mair mons Lateral O Canal MAN©– 16" Reuse Water Main – 57
<br />Street to (i3''Street .
<br />This sworn statement is submitted by:__ Tri --Sure Corporat.ion
<br />(Name of entity submitting sworn statement)
<br />whose business address is: P • a • Box 653, Auburndale, Fl, 33823
<br />— _
<br />arid (if applicable) its Federal
<br />Employer identification Number (FEIN) is s 19-14 98 14 5
<br />2. My name is Jason Chambers
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is President
<br />3. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County Code,
<br />means:
<br />Tile term "afliliate" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are active in the management of the entity.
<br />4. 1 understand that the relationship with a County Commissioner or County employee that must
<br />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-law,
<br />daughter-in-law, son-in-law, brother-in-law, sister-in-law, stepfather,
<br />stepmother, stepson, stepdaughter, stepbrother, stepsister, half
<br />brother, half sister, grandparent or grandchild.
<br />5. 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 />N Neither the entity submitting this swam 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 />00452-1
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