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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 />STATE OF V� <br />COUNTY OF <br />Name of County Commissioner <br />or employee <br />Relationship <br />ACL'�' - <br />Cert r�`Kfn.n/ �r <br />tUQ� �i..pE c��11 <br />v (Date) <br />4h <br />The foregoing instrument was acknowledged before me this day of AU0 L 201_�L by <br />v e) e, -h( -.o, -n personally ` ,who is ersonall known to me or who has produced <br />n as identification. <br />NOTARY PUBLIC <br />SIGN: <br />PRINT:n <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) ��t;r «y p,�ulic 5:?tr of Florida <br />4! 6 !,are;.-, A, RicketSQn ` <br />ssicn FF 0-0168 <br />pd Ex-pires 1o11512017 a <br />00452-2 <br />F:\PublicWorks\ENGINEERING DIVISION PROJECTS\1643 27th Avenue at 21st Street SW Intersection_Signalization Improvements\1-Admin\Bid <br />Dc -A ments\Mas�.Inr Contract Documents100452 Disclosure of Relahonships.¢R^.t . _ -,mow• <br />