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STATEMENT UNDER SECTIOti iN DI AN RIVER COUNTY CODE,
<br /> ON DISCLOSURE OF IRELATIONSHIPS
<br /> ,R-N4 MUST BE SIGNED IN THE PRESENCE Or A \OTARY PUBLIC OR OTHER OFFICER
<br /> _ RIZED TO ADMINISTER OATHS.
<br /> sworn statement MUST be submitted with Bid, Proposal or Contract No. G^-W` 2-
<br /> sworn statement is submitted by: /
<br /> (Name of entity submitting Statement)
<br /> -.ose business address is:
<br /> name is `Q
<br /> (Plea print name of individual signing)
<br /> -d my relationship to the entity named above is
<br /> _;.�derstand that an"affiliate" as defined in Section 105.08, Indian River County Code, means:
<br /> -e term"affiliate" includes those officers, directors, executives, part ners,.shareholders, employees,
<br /> -embers, and agents who are active in the management of the entity.
<br /> is
<br /> : :understand that the relationship with a County Commissioner or County employee that must be
<br /> sclosed as follows:
<br /> ather, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife,
<br /> -law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, stepfather,
<br /> azher-in-law, mother-in
<br /> ; e mother, stepson, stepdaughter, stepbrother, stepsister, half brother; half sister, grandparent, or
<br /> p
<br /> randchild.
<br /> Bas
<br /> ed on information and belief, the statement, which I have marked below, is true in relation to the
<br /> entity submitting this sworn statement. [Please indicate which statement applies.]
<br /> _Werther 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. «N ith any County Commissioner
<br /> or County employee.
<br /> 00452-1
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