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SECTION 00452 — Sworn Statement on Disclosure of Relationships
<br />SWORN STATEMENT UNDER SECTION 105.05, INDIAN RIVER COUNTY CODE,
<br />ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />AUTHORIZED TO ADMINISTER OATHS.
<br />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2022009
<br />for JACKIE ROBINSON TRAINING COMPLEX — VILLAS REMODEL
<br />2. This sworn statement is submitted by: '0'1 I 'T off C -o Insl—a ( o 4 0 n
<br />mQari `1, 1 nC .
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />.49, �-Akvf� -ikirinot
<br />M� (��Lqo(
<br />3. My name is
<br />(Please print name of individual signing) � (�
<br />and my relationship to the entity named above is gyzslC((��,�,1J'V�
<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, employees,
<br />members, and agents who are active in the management.of the entity.
<br />5. 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 />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 />Sworn Statement of Disclosure of Relationships - 00452-1
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<br />0_2_Bidding Documents - 20201002 docz
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