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SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF
<br /> RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO
<br /> ADMINISTER OATHS.
<br /> 1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2016026 for
<br /> 58th Avenue Pavement Reclamation and Resurfacing Project—57th Street to CR-510(FDOT
<br /> SCOP FM No.434416-1) (IRC Proiect No. 1325)
<br /> 2. This sworn statement is submitted by:
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> and its Federal Employer Identification Number(FEIN) is
<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,
<br /> employees, 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
<br /> be 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
<br /> to the entity submitting this sworn statement. [Please indicate which statement applies.]
<br /> Neither the entity submitting this sworn statement, nor any officers, directors, executives,
<br /> partners, shareholders, employees, members, or agents who are active in management of the
<br /> entity, have any relationships as defined in section 105.08, Indian River County Code, with any
<br /> County Commissioner or County employee.
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