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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. 2017034
<br />for CR512 WESTBOUND RESURFACING (ROSELAND ROAD TO US1) AND CR512
<br />EASTBOUND RESURFACING (EASY STREET TO US1)
<br />2. This sworn statement is submitted by: M1,0 5<--esmilleruivr
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />1.c013StuOvd,%4AN14nISNtksL 11evotPa41 -R. 3-0(2-2-
<br />3. My name is
<br />(Please
<br />t name of individual signing)
<br />and my relationship to the entity named above is Pit,
<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, 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 1 have marked below, is true in relation to the
<br />entity submitting this sworn statement. [Please indicate which statement applies.]
<br />iC) 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\1139-CR 512 Wbnd Resurfacing -Roseland Rd to US 1-SCOP\Admin\bid documents\Master
<br />Contract Documents\00452 Disclosure of Relationships.doc
<br />
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