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SECTION 00452
<br />SWORD STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY
<br />CODE, ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />1. This sworn statement MUST be submitted with Bid No. 2021026
<br />for South Oslo Road WTP Improvements
<br />This sworn statement is submitted by: TLC Diversified, Inc.
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />2719 17th Street East, Palmetto, FL 34221
<br />3. My .name is Dalas Lamberson
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is
<br />Vice 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 />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 />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
<br />grandchild.
<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 />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 or
<br />County emploYee.
<br />The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners,
<br />shareholders, employees, members, or agents, who are active in management of the entity have the
<br />following relationships with a County Commissioner or County employee:
<br />00452-1
<br />155
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