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The entity submitting .this sworn statement, or one or more of the officers, directors; executives, <br />partners, shareholders, employees, members, or agents, who are active in management of the entity <br />have the :following relationships with a County Commissioner or County employee: <br />Name of Affiliate <br />or entity <br />STATE OF FLORIDA <br />COUNTY OF ST. LUCIE <br />Name of County Commissioner <br />or employee. <br />Relationship. <br />_ #" <br />(Signature) <br />MARCH 2,2M <br />(Date) <br />Sworn to (or affir%(R&:,1 and subscribed before .me by means of.IZ physical presence or ❑ .online notarization, <br />this -2ND day of 20 21 , by LARRY T. DALE (na _ e' of person making <br />statement) : <br />yA�o Cynthia Clark Cheatham <br />oP NOTARY PUBLIC (Sign ure of Notary Public - State of Florida) <br />+STATE OF FLORIDA (Print, Type, or Stamp Commissioned Name of Notary Public) <br />Cornni# GG331046 <br />INCE 19Expires 5/6/2023 <br />IM who is personally known to me or 0 who has produced <br />as identification. <br />END OF SECTION <br />00452,2 <br />F.\P.ublic Works\ENGINEERING DIVISION PROJECTS\1927 Round Island Beach Access\1-Admin\Bids\Bid DocumentsWaster,Contract <br />Documents\00452 - Disclosure of Relationships.doc <br />