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SECTION 00452
<br /> SWORN STATEMENT UNDER SECTION 105.08, 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. 2016019
<br /> for I.R.C. GO LINE TRANFER HUB - IRC NO. 1330
<br /> 2. This sworn statement is submitted by: Barth Construction, Inc.
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> 1717 Indian River Blvd, Suite 202A, Vero Beach, FL 32960
<br /> 3. My name is Phil Barth
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is President
<br /> 4. I 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. 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, .moth'er`in=law;";'daughter= nY;aw, son-in-law, brother-in-law, sister-in-law, stepfather,
<br /> stepmother stepson S. prgtiter, ste brstepsister, 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 /> 00452-1
<br /> PABids\2015-2016 FY(2016000)\2016019-GoLine Transfer Hub\Bid Docs\Word forms\00452 Disclosure of Relationships.doc
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