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A . Indian River County 45th Street RFQ # 2018012 d. Disclosure of Relationships & Licenses SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF RELATIONSHIPS THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2018012 for 4Sth Street Pavement Milling and Resurfacing Project — S8th Avenue to 43rd Avenue (IRC 1722) (FDOT SCOP FM No. 434848-1) 2. This sworn statement is submitted by: Masteller & Moler, Inc. (Name of entity submitting Statement) whose business address is: 1655 27th Street, Suite 2, Vero Beach Florida 32960 and its Federal Employer Identification Number (FEIN) is 59-2538792 3. My name is Stephen E. Moler. PE (Please print name of individual signing) and my relationship to the entity name above is Vice President 4. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County Code, means: The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of the entity. 5. 1 understand that the relationship with a County Commissioner or County employee that must be disclosed as follows: Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister- in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or grandchild. 6. Based on information and belief, the statement, which I have marked below, is true in relation to the entity submitting this sworn statement. [Please indicate which statement applies.] Page 10 of 11 M1 - CIVIL ENGINEERS - g. DISCLOSURE & LICENSES I PAGE 1