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IRC-2025—ITB—FLEET FACILITY GAS ISLAND CANOPY REFURBISHMENT
<br />SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF
<br />RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO
<br />ADMINISTER OATHS.
<br />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2021024
<br />for FLEET FACILITY FUEL ISLAND CANOPY REFURBISHMENT
<br />2. This sworn statement is submitted by:
<br />JSR Enterprises East Coast, LLC. d/b/a JSR Fueling Technologies, LLC.
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />3111 Skyway Circle, Suite 111, Melbourne, FL 32934
<br />and its Federal Employer Identification Number (FEIN) is 46-30351
<br />3. My name is Joshua Ghiz
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is
<br />Owner/ Contractor
<br />4. 1 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,
<br />employees, members, and agents who are active in the management of the entity.
<br />I understand that the relationship with a County Commissioner or County employee that must
<br />be disclosed as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece,
<br />husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-
<br />in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother,
<br />half sister, grandparent, or grandchild.
<br />6. Based on information and belief, the statement, which I have marked below, is true in relation
<br />to the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />✓ Neither the entity submitting this sworn statement, nor any officers, directors, executives,
<br />partners, shareholders, employees, members,;or agents who are active in management of the
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