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<br />^' Indian River C
<br />d. Disclosure of Relationships & Licenses
<br />45th Street Milli
<br />& Resurfacin
<br />RFQ # 2018012
<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. 2018012
<br />for 45th Street Pavement Milling and Resurfacing Project — 58th Avenue to 43rd Avenue (IRC
<br />1722) (FDOT SCOP FM No. 434848-1)
<br />2. This sworn statement is submitted by: Masteller & Moler, Inc.
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />1655 27th Street, Suite 2, Vero Beach Florida 32960
<br />and its Federal Employer Identification Number (FEIN) is 59-2538792
<br />3. My name is Stephen E. Moler. PE
<br />(Please print name of individual signing)
<br />and my relationship to the entity name above is Vice President
<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, employees,
<br />members, and agents who are active in the management of the entity.
<br />5. 1 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, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, 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 to
<br />the entity submitting this sworn statement. [Please indicate which statement applies.]
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<br />M MASTELLER & MOLER, INC. g. DISCLOSURE & LICENSES I PAGE 1
<br />M CIVIL ENGINEERS
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