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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. 2017013
<br /> for 431 AVENUE SIDEWALK IMPROVEMENTS FROM AVIATION BOULEVARD TO
<br /> AIRPORT DRIVE WEST—IRC NO. 1123
<br /> i
<br /> 2. This sworn statement is submitted by: -,t—
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> o �,� �� 4k30�7& Z
<br /> 3. My name isa
<br /> (Pl se print name of individual signing)
<br /> I
<br /> and my relationship to the entity named above is CA MN`6,
<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 /> 00452-1
<br /> F-\Public Works\ENGINEERING DIVISION PROJECTS\1123 43rd Ave Sidewalk Improvements 26th St.to Airport Dr West\Admim\bid
<br /> documents\Master Contract Documents\00452 Disclosure of Relationships.doc
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