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SWORN STATEMENT ON DISCLOSURE OF RELATIONSHIPS AND
<br /> DISCLOSURE OF FINANCIAL CONFLICT OF INTEREST
<br /> ,,,,,,.SIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br /> AUTHORIZED TO ADMINISTER OATHS.
<br /> 1. This sworn statement MUST be submitted with Local Jobs Grant Applications.
<br /> 2. This sworn statement is submitted by:
<br /> Triton Submarines,LLC
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> 901517'h Place, Vero Beach,FL 32966
<br /> 3. My name is Patrick Lahey
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is Owner and President
<br /> I understand that an "affiliate" 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. I 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. I understand that business relationships and other financial relationships between affiliate and a
<br /> County Commissioner or County employee, as each of these terms are defined under items 4 and 5
<br /> above, must be disclosed as part of this sworn statement.
<br /> 7. Based on information and belief, the Disclosure of Relationships statement, which I have marked
<br /> below, is true in relation to the entity submitting this sworn statement. [Please indicate which
<br /> statement applies.]
<br /> X Neither the entity submitting this sworn statement, nor any officers, directors,
<br /> executives, partners, shareholders, employees, members, or agents who are active in management of
<br /> the entity, have any relationships as defined under item number 5 above, with any County
<br /> Commissioner or County employee.
<br /> Local Jobs Grant Applicant Sworn Statement on Disclosure of Relationships Page 1 of 3182
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