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SECTION 00452
<br />SWORN STATEMENT UNDER SECTION 105.08, 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 />This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2018009
<br />for CR 512 RESURFACING & SHOULDER WIDENING FROM MYRTLE STREET
<br />TO 125th' AVENUE
<br />1 This sworn statement is submitted by: Conu-nunity Asphalt Corp.
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />2975 Industrial Blvd Vero Beach FL 32967
<br />3. My name is' Manuel
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is Corporate 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 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-in-law, 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 below, is true in relation to the
<br />entity submitting this sworn statement. [Please indicate which statement applies.]
<br />X 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 any
<br />relationships as defined in section 105.08, Indian River County Code, with any County Commissioner
<br />or County employee.
<br />00452-1
<br />FAPubIicWorks\ENGINEERING DIVISION PROJECTS\1305-CR 512 Resurf(SCOP)_Myrtle St to 125th St\Admim\bid documentsWaster Contract
<br />Documents\00452 Disclosure of Relationships.doc
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