|
2015015 - Head Island
<br />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. 2015015
<br />for Removal of Fill from Indian River Aquatic Preserve and Restoration of Head Island
<br />2. This sworn statement is submitted by:
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />(-J 13.v ca -o--e atac 1201 s - Bu -. ,F& 34770 -
<br />and its Federal Employer Identification Number (FEIN) is 24-2-10
<br />3.. .Myname is
<br />W n449- e
<br />(Pleaser}frint name of individual signing)
<br />and my relationship to the entity named above is
<br />M
<br />4. I understand that an "affiliate" as defined in Section 105.08, Indian River County Code, means:
<br />T-heterm.'=affiliate" includes -thaw -o#f leers ldir-ect-ors; -exectutives, Dart era, shareholders,
<br />employees, members, and agents who are active in the management of the entity.
<br />5. 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,
<br />,husband, wife, fatter4in-law, inotl erl in,law; •d ter-ln- law, sGr44n aw; -k -rtt# of -4aw, sister-
<br />in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother,
<br />half sister, grandparent, or 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 />Page 13 of 25
<br />185
<br />
|