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SWORN STATEMENT UNDER SECTION 305.08,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 /> I. This sworn statement MUST be submitted with Bid,Proposal or Contract No. 2016026 for
<br /> 58'^Avenue Pavement Reclamation and Resurfacing Prolect—57th Street to CR-510(FOOT
<br /> SCOP FM No.434416-1)(IRC Prolect No.132S)
<br /> 2. This sworn statement is submitted by: V50C Jm0.A CnnSu I fine GrouP L_TU�i_
<br /> i-
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> Z141 50 W. Gaut"-I. 2A n
<br /> and its Federal Employer Identification Number(FEIN)is r..)q I (67-15 1
<br /> 3. My name is Ei L JQIiav\n
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is GT0_V\C-1n
<br /> i
<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 /> S. I 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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