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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 />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2019050
<br />for OGLE TRAIL ,SHORELINE STABILIZATION PROJECT
<br />2. This swam statement is submitted by: XG10 Syms,1LLC
<br />whose business address is:
<br />(Name of entity submitting Statement)
<br />415 NW Flamer Avenue, Stuart, Fkoricla 34994`
<br />3. My name is Geoff Corlett
<br />(Please print name of individual signing)
<br />andmny relationship to the entity ziamed'above is CEO
<br />4. understand that an "a11i�e" as dlefined in Seton 105.48, find Tan 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. I 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-Iaw, stepfather,
<br />stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or
<br />grandchild.
<br />6. Based on infonnation and belief, the statement, which I ;have marked below, is true in relation to the
<br />entity sulmnitting this SW, statement. Please indicate w1iich 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 />F:\Public Works\ENGINEERING DIVISION PROJECTS\1823 Jungle Trail Shoreline Stabilization Project (2018)\1-Admin\Bid Documents\Master
<br />Contract Documents100452 Disclosure of Relationships.doc
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