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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. 2021025
<br />for ROUND ISLAND PARK Er4ERGENCY AND HEAVY EQUIPMENT BEACH ACCESS
<br />This sworn statement is submitted by: DICKERSON FLORIDA INC.
<br />whose business address is:
<br />My name is
<br />(Name of entity submitting Statement)
<br />3122 N. 25TH ST:, FT. PIERCE, FL 34946
<br />LARRY T. DALE
<br />(Please print name of individual 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, Indian 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. 1 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 />father4n-law, mother-in-law, daughter-in-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 />b. 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 />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 />FAPublic Works\ENGINEERING DIVISION'PROJECTS\1927 Round Island Beach Access\1-Admin0ds\Bid_ DocumentsWaster Contract
<br />Documents\00452 - Disclosure of Relationshi,ps.doc
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