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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 />entity, have any relationships as defined in section 105.08, Indian River County Code, with any <br />County Commissioner or County employee. <br />The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents, who are active in <br />management of the entity have the following relationships with a County Commissioner or <br />County employee: <br />Name of Affiliate Name of County Commissioner Relationship <br />or entity or employee <br />(Signature) <br />(Date) <br />STATE OF <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this day of 20J by <br />is personally known to me or who has produced <br />as identification. <br />SIGN: <br />PRINT: <br />(Seal) <br />Page 11 of 11 <br />NOTARY PUBLIC <br />Notary Public, State at large <br />My Commission Expires: <br />26 <br />