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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 Indian River <br />Name of County Commissioner <br />or employee <br />Relationship <br />(Signature) <br />4/29/21 <br />(Date) <br />Sworn to (or affirmed) and subscribed before me by means of ® physical presence or ❑ online <br />notarization, this 29th April day of 20 21 , by William Lasky Jr (name of <br />person making statement). <br />) <br />cu& <br />( ignat re of Notary Public - State of Florida) <br />(Print, Type, or Stamp Commissioned Name of Notary Public) <br />® who is personally known to me or ❑ who has produced <br />as identification. <br />"arP� DEBORAH L. AUSTIN <br />,. Commission # GG 165615 <br />;e Expires January 6, 2022 <br />Bonded Thru Troy Fain Insurance 800385.7019 <br />Sworn Statement of Disclosure of Relationships - 00452-2 <br />F:\Pub1icWorks\ENGINEERING DIVISION PROJECTS\1764 IRC Courthouse Roof Replacement\1'-Admin\Bids\Bid Documents\Mester Bid Documents\DIV 0_2 Bldding Documents • 20201002.docx <br />