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SECTION 00452
<br />SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE,
<br />ON DISCLOSURE 01? RELATIONSHIPS
<br />THIS FORM. MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />AUTHORIZED TO ADMINISTER OATHS.
<br />I . This sworn statement MUST be submitted with Bid, Proposal or Contract No. 20190.12
<br />for VERO LAKE ESTATES: 85m. STREET MILLINGS FROM 1015â–º AVENUE
<br />TO 961h AVENUE
<br />2. This sworn statement is .submitted by: Timothy Rose Contracting
<br />(Name of entity submitting Statement)
<br />whose business .address is:
<br />136o SW Old Dixie Hwy Suite 106 Vero Beach FL 32962
<br />3. My iiaine is
<br />Timothy Rose
<br />(P.lease print name ofindividual signing)
<br />and my relationship to the entity named above is. President
<br />4. I understand that an "affiliate" as defined in Section 105.08, IndianRiver County Code, means:
<br />The term "affiliate" includes those officers, directors, executives, partners, shareholders, en ployees,
<br />members, and agents who are active in the management .of the entity..
<br />5. I understand that the relationship with a County Corrimissioner 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• -iii -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 />XX Neither the -entity submitting this sworn stateinent, nor .any officers, directors, executives, partners,
<br />shareholders, -employees, meinbers, 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:\PublicVVorks\ENGINEERING DIVISION PROJECTS11628-85th Street 96111 Ave to 401st Ave_ Roadway.lrnprovements\1 Admin\Bids\Bid
<br />Documents\Master Contract Documents\00452 Disclosure of Retalionships.doc
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