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SWORN STATEME NT UNDER SECTION 105.089 INDIIAN RIVER COUNTY CODE.,
<br /> ON DISCLOSURE Oy RJELATIONS111pS
<br /> TMS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIc oR OTRE
<br /> A,UTH0R_TZED TO ADMINISTER OATIJS. CER
<br /> This sworn statement MUST be submitted with Bid,Proposal or Contract No. 2012040
<br /> for Sandridae Golf Course—Drivin lane Tee Renovations
<br /> 2. This sworn statement is submitted by:
<br /> (Name of entity submitting Statement)
<br /> whose business address is.-
<br /> K47
<br /> `'p p r- c ;f F`Y ,_ :. r-
<br /> 316 My name is
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is _�2
<br /> I �i 7. A 7 91
<br /> 4. 1 understand that an "affiliate"as defined iii Section 105.08, Indian River County Code,means:
<br /> The term"affiliate"includes those officers, directors, executives,partners, shareholders, employees,
<br /> members, and agents who are active in the management of the entity.
<br /> 5. 1 understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed as follows:
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin,, nephew, niece, husband,, wife.,
<br /> father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, stepfather,
<br /> stepmother, stepson., stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or
<br /> grandchild.
<br /> 6. Based on information and belief, the statement, which I have marked below, is true in relati•
<br /> on to the
<br /> entity submitting this sworn statement. [Please indicate which statement ap'plies.]
<br /> Neither the entity submitting this sworn statement, nor any officers, directors executives, partners.,
<br /> shareholders, employees, members, or agents who are active in management of the entity, have any
<br /> relationships as defined M* section 105.08, Indian River County Code, with any County Coinn.,*ss*
<br /> or County employee. i loner
<br /> The entity submitting this sworn statement, or one or more of the officers., directors-, executives.,
<br /> partners, shareholders, employees., members, or agents, who are active in management of the entity
<br /> 0
<br /> have the following relationships With a County Commissioner or County employee,
<br /> 00452-1
<br /> FAPublic worksXENGINEERING DIVISION PROJECTSM10-Sandridge Driving Range Tee Renovation\Admim\bjd documentS100452 Disclosure ar
<br /> Psa1_qHnnqhfn_-z rinn IG
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<br /> Sm—ea–dSoft-Re—pri ff-D–are--.Monday,January 11,2016 m 09:21:49 m officialDoUments:9069,Attachment Id 1,Page 27
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