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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 />Name of Affiliate <br />or entity <br />Name of County Commissioner Relationship <br />or employee <br />(Signature) <br />May 24, 2017 <br />(Date) <br />STATE OF Florida <br />COUNTY OF Indian River <br />The foregoing instrument was acknowledged before me this 2,14 day of Wieuki , 20 17 by <br />Vd 1 1 t B Sttit-(/1 , who islirmnally knoll me or who has produced <br />as identification. <br />NOTARY PUBLIC <br />� <br />SIGN: �% <br />t, <br />_ <br />PRINT: ! r, c,� c�(1/� <br />W a ✓'-,, <br />Notary Piblic, State at large <br />My Commission Expires: <br />(Seal) <br />1 Z. CHRISTY SCHWARTZ <br />MY COMMISSION # FF 936557 <br />EXPIRES: Octobor 21, 2018 <br />pit.E Wallin bigot Notary kith's <br />00452=2 <br />• <br />F:\Public Works\ENGINEERING DIVISION PROJECTS11621 IRC Courthouse Judges Security Upgrades\1-Admin\Bid Documents\Master Contract <br />Documents100452 Disclosure of Relationships.doc <br />