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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.
<br />This sworn statement is submitted with Bid, Proposal or Contract No.2000, or the North
<br />WTP Raw Water Transmission System.
<br />1. This sworn statement is submitted by: -I—[VVI ot�,v1rZ��zC�,v«_
<br />(Name. oY entity submitting sworn state ent)
<br />whose business address is: 13�� S11) O t Dike �_ .n . I 1w,
<br />and
<br />_
<br />(if applicable) its Federal Employer Identification Number (FEIN) is tpS= O Lq-S��}�
<br />2. cviy name iS l G VVl(� lil \i1 • c—
<br />(Please print ame of individual signing)
<br />and my relationship to the entity named above.Js
<br />3. I understand that an "affiliate" as defined in Section 105.08, Indian River County Code,
<br />means:
<br />"affiliate"
<br />The term includes those officers, directors, executives, partners,
<br />shareholders, employees, members, and agents who are active in the management
<br />of the entity.
<br />4. 1 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 and belief, the statement which I have marked below is true in
<br />relation to the entity submitting this sworn statement. Please indicate which statement
<br />applies_
<br />XNeither the entity submitting this sworn statement, nor any officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active
<br />in management -of the entity, have any relationships as defined in Section 105.08,
<br />Indian River County Code, with any County Commissioner or County employee.
<br />f The entity submitting this sworn 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 />Name of Affiliate Name of Count Relationship
<br />00452-1
<br />
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