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=in <br />6. Based on information and belief, the statement which I have marked below is true in relation to <br />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 <br />management of the entity, have any relationships as defined in Section 105.08, Indian <br />River County Code, with any County Commissioner or County employee. <br />The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in <br />management of the entity have the following relationships with a County Commissioner or <br />County employee: <br />Name of Affiliate Name of County Commissioner Relationship or Entity or employee <br />[signature] <br />[date] <br />STATE OF <br />COUNTY OF <br />The foregoing instrument was acknowledged before me <br />this day of . 19_, by_-_, who is personally known to me <br />or whoTas produced as identification <br />NOTARY PUBLIC <br />sign: <br />print: <br />State of Florida at large <br />My Commission Expires: <br />(Seal) <br />36 <br />