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IM <br />,-'nw��,......w...-�.:_�.....—J.�.�. - �—Tyr-Y.J-.-...---•--.�...w�---_r. ...-.mss-�.rr�--...... <br />S. <br />SWORN STATEMENT UNDER SECTION 105.08, <br />INDIAN RIVER COUNTY 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 is submitted with Bid, Proposal <br />or Contract No. for <br />2. This sworn statement is submitted by: <br />[name of entity submitting sworn statement] <br />whose business address is: <br />and (if applicable) its Federal Employer Identification Number <br />e <br />(FEIN) 1S: (If the entity has no FEIN, include the Social Security <br />Number. oft the individual signing this sworn statement. ) <br />3. My name is <br />[please print name of individual signing] <br />and my relationship to the entity named above is <br />4. I understand that an "affiliate" as defined in Section 105.08, INDIAN RIVER COUNTY Code, <br />means: <br />The term "affiliate" includes those officers, directors, <br />executives, partners, shareholders, employees, members, <br />and agents who are active in the management of the entity, <br />5. I understand that the relationship with a County Commissioner or County employee that must <br />be disclosed is as follows: <br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, <br />F 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, half <br />sister, grandparent or grandchild. <br />Al <br />J ki <br />35 <br />0 <br />