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The entity submitting this sworn statement, or one or more of the officers, directors, executives, <br />partners, shareholders, employees, members, or agents, who are active in management of the entity <br />have the following relationships with a County Commissioner or County employee: <br />Name of Affiliate Name of County Commissioner Relationship <br />or entity or employee <br />(Signature) <br />03.13.19 <br />STATE OF Florida <br />COUNTY OF Indian River <br />The foregoing instrument was acknowledged before me this 13th day of March <br />(Date) <br />, 2019. by <br />, who is personally known to me or who has produced <br />as identification. <br />SIGN: <br />NOTARY PUBLIC <br />PRINT: Deborah West <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) <br />00452-2 <br />Diii3ORAH WEST P5 <br />MY COMMISSiON 44904' 72 <br />E PO ES: Octob 03, 2019 r <br />(Sj <br />F;Public Works\ENGINEERING DIVISION PROJECTS\1362-OId Dixie Hwy_Highland Dr11-Admin\Bid Documents\Master Contract Documents\00452 <br />Disclosure of Relationships.doc <br />