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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. 201 026 for
<br />$801 Avenue Pavement Reclamation and Resurfacing Prosect —571h Street to CR -510 (FOOT
<br />SCOP FM No. 434416-1) URC Project No. 1325)
<br />2. This sworn statement is submitted by: V!)Q >n 1Q41 innsully'%Q Gly -24>6i I Til
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />L1450 W. eour r._11i,-rY
<br />�1�rrl,su1�Q232'1el�wv,, EL SI -55Y
<br />and its Federal Employer Identification Number (FEIN) ismer' '-f — t _' (07.16 1
<br />3. Mynameis E.'61L J0kiayNn
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is &'CLyN r•H m n'.naQc1C
<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 />VNeither 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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<br />P103
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