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SWORN STATEMENT UNDER SECTION 105.089 INDIAN RIVER COUNTY CODE,
<br /> ON DISCLOSURE OF RELATIONSHIPS
<br /> THIS 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 Bid,Proposal or Contract No. 2012040
<br /> for Sandridge Golf Course—Driving Range Tee Renovations
<br /> 2. This sworn statement is submitted by:
<br /> z_
<br /> 3
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> C7
<br /> 3• My name is
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is
<br /> 4. 1 understand 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 /> 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 relation to the
<br /> entity 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 /> 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 /> have the following relationships with a County Commissioner or County employee:
<br /> 00452-1
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