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SECTION 00452
<br />SWORN STATEMENT UNDER SECTION 105.089 INDIAN RIVER COUNTY CODE,
<br />ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />AUTHORIZED TO ADMINISTER OATHS.
<br />ESI
<br />2.
<br />This sworn statement MUST be submitted with Bid, Proposal or Contract No. .20 8021
<br />PROJECT
<br />This sworn statement is submitted by:
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />3. My name is ��(� j LG;S
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is t Lr= 41SIA441'
<br />4. I 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 be
<br />disclosed as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife,
<br />father-in-law,mother-in-law, daughter-in4aw, son-in-law, brother-in-law, sister -in - law, stepfather,
<br />stepmother, stepson, stepdaughter, stepbrother, stepsister, half . brother, half sister, . grandparent, or
<br />grandchild.
<br />6. Based on information and belief, the statement, which I have. marked bellow, is take in relation to the
<br />entity submitting this sworn statement, [Please:indicate which statement applies.]
<br />Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in management of the entity, have my
<br />relationships as defined in section_ 1.05.08, Indian River County Code, with any County Commissioner
<br />or County employee.
<br />00452-1
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