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SECTIk_
<br />-..s _-} RN STATEMENT UNDER SECTION ; .7",.i1). I N D I AN RIVER COUNTY CODE,
<br />ON DISCLOSURE OF Pf LA T IONSHIPS
<br />_ M MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />_•_-?.IZED TO ADMINISTER OATHS.
<br />sworn statement MUST be submitted with Bid, Proposal or Contract No. O \ Z-
<br />tiq \L:utsikkoat&ALIA/ Aft__ k lonvefike n�� D 0( TS .5)- ye :
<br />s sworn statement is submitted by: //t144'341/ k) CeOtrad--2-a--
<br />(Name of entity submitting Statement)
<br />nose business address is:
<br />1 iSuit is & -3Z.
<br />v name is ---17—t
<br />(Plea print name of individual signing
<br />_rld my relationship to the entity named above is
<br />rel. 16641-
<br />,_mderstand that an "affiliate" as defined in 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 />understand that the relationship with a County Commissioner or County employee that must be
<br />sclosed 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 />:epmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or
<br />randchild.
<br />Based on information and belief, the statement, which I have marked below, is true in relation to the
<br />_ntity submitting this sworn statement. [Please indicate which statement applies.]
<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 in section 105.08, Indian River County Code, with any County Commissioner
<br />or County employee.
<br />00452-1
<br />Works\ENGINEERING DIVISION PROJECTS -C -=5g - Old Dixie Hwy Sidewalk (38th Ln - 45th
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