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Exhibit B. Disclosure of Relationships
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY
<br />PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />This sworn statement is submitted with that certain Agreement for Donation of Surplus
<br />County -Owned Lands a
<br />1. This sworn statement is submitted by: �� " A 1 - <<'—
<br />(Nam ntity submitting sworn statement)
<br />whose business address is: dl 9q,
<br />AA�� ,
<br />e_ fo&AL-
<br />and
<br />(if applicable) its Federal Employer Identification Number (FEIN) iso-olq�gcii,
<br />My name is J tk K0-Ylyl-,L", � ©r, Ce—
<br />(Please print name of individual signing)
<br />-gpning)
<br />And my relationship to the entity named above is eSlc�-e-yC'�
<br />3. In understand that an "affiliate" as defined in Section 105.08, Indian River County
<br />Code, means:
<br />The term "affiliate" includes those officers, directors, executives, partners,
<br />shareholders, employees, members, and agents who are active in the
<br />management of the entity.
<br />I understand that the relationship with a County Commissioner or County employee
<br />that -must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew,
<br />niece, husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law,
<br />brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter,
<br />step -brother, stepsister, half-brother, half-sister, grandparent or grandchild.
<br />Based on information and belief, the statement which I have marked below is
<br />true in relation to the entity submitting this sworn statement. [Please indicate
<br />which statement applies.]
<br />Neither the entity submitting this sworn statement, nor any officers,
<br />directors, executives, partners, shareholders, employees, members, or agents
<br />who are active in
<br />management of the entity, have any relationships as defined in Section 105.08, Indian
<br />River County Code, with any 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 />F.\Community Development\COUNTY OWNED LANDS\2019\AGREEMENT BETWEEN IRC AND EDHAP.docx
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