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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />JEXMItB,ICt7,.K <br />2019040 - RFQ for CEI Services - 43rd Ave <br />SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF <br />RELATIONSHIPS <br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO <br />ADMINISTER OATHS. <br />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2019040 <br />for Construction Engineering and Inspection (CEI) Services for IRC -0853 — 43rd Avenue (18th <br />Street to 26th Street). <br />2. This sworn statement is submitted by: <br />(Name of entity submitting Statement) <br />whose business address is: <br />and its Federal Employer Identification Number (FEIN) is <br />3. My name is <br />(Please print name of individual signing) <br />and my relationship to the entity named above is <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, <br />employees, members, and agents who are active in the management of the entity. <br />5. I understand that the relationship with a County Commissioner or County employee that must <br />be disclosed as follows: <br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, <br />husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister- <br />in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, <br />half sister, grandparent, or grandchild. <br />6. Based on information and belief, the statement, which I have marked below, is true in relation <br />to the entity submitting this sworn statement. [Please indicate which statement applies.] <br />Page 12 of 15 <br />