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-�. SWORN STATEMENT UNDE i' SECTION 1O5 08, IN IAN RIVE"' COUNTY CODE,
<br />ON DISCEOSU E OF RELATIONSHIPS
<br />En THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />NI AUTHORIZED TO ADMINISTER OATHS.
<br />ei1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2014044
<br />for Old Dixie Highway Resurfacing (From the I.R.F.W.C.D. North Relief Canal to 71st Street)
<br />This sworn statement is submitted by: veva ejU o cf t s-'
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />k uoao oka,N,\Icc.-Awy 5v. k.OL sat3eiriloff... 3z%(02.
<br />My name is 1.1AAA
<br />ease print name of individual signing)
<br />and my relationship to the entity named above is P €3.6.af2
<br />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 />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. 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 />directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in tnanagement tof the entity, have any
<br />Neither the entity submitting this sworn statement, nor any officers,
<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
<br />F:\Public Works\ENniNFFRiNn nnncinni ppc) IFr-rs\1137-Oid Dixie Hwy Resurfacing IRF North Relief Canal to 71st St\Admim\bid
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