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SECTION 00452 - Sworn Statement on Disclosure of Relationships
<br />SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, ON
<br />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. 2021018
<br />for 6.6_T" AVENUE ROADWAY WIDENING 149TH STREET TO 69tH STREET) — IRC -1505
<br />2. This sworn statement is submitted by: Halley Engineering Contractors, Inc.
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />13901 NW 118th Ave, Miami, FL 33178
<br />3. My name is Daniel I. Halley P.E.
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is President
<br />4. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County Code, means.-
<br />The
<br />eans:
<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 />S. 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-law, stepfather,
<br />stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or t
<br />grandchild. s
<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 />V 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 />Sworn Statement of Disclosure of Relationships - 04452.1
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