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Indian River County 45th Street <br />& Resurfaci <br />RFQ # 2018012 <br />X 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 <br />or entity <br />STATE OF Florida <br />COUNTY OF Indian River <br />Name of County Commissioner <br />or employee <br />Relationship <br />(Signature) <br />( Date) <br />The foregoing instrument was acknowledged before me this day ofr_, 201- by_ <br />Stephen E. Moler who is personally know to me r who has produced <br />as identification. <br />M <br />M <br />,STELLER & MOLER, INC. <br />CIVIL ENGINEERS N <br />NOTARY PUBLIC <br />I <br />SIGN: <br />PRINT: �J/ '^ /ass <br />Notary Public, State at large <br />My Commission Expires: laloq/18 <br />(Seal) <br />CINDY L. BASS <br />Commission # FF 114661 <br />Expires December 9, 2016 <br />''atf..•' eemanwrropvwN«m+rJ0o4r6�9�! <br />Page 11 of 11 <br />g. DISCLOSURE & LICENSES I PAGE 2 <br />44 <br />