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The entity submitting this sworn statement. or one or more of the officers, directors, executives, <br />partners, shareholders, employees, members, or agents, who are active in management of the entity <br />have the following relationships with a County Commissioner or County employee: <br />Name of Affiliate <br />or entity <br />STATE OF <br />COUNTY OF ' <br />Name of County Commissioner <br />or employee <br />Relationship <br />(Signature) <br />(Date) <br />Sworn to (or affirmed) and subscribed before me by means of ❑ physical presence or ❑ online <br />notarization, this i day of 20 by <br />(name of person making statement). E <br />(Signature of Notary Public - State of Florida) <br />(Print, Type, or Stamp CoYnmissioned Name of Notary Public) <br />e� QOM HSA O . <br />who is personally known to me or 11who has produced = �x�` 5 <br />as identification. - • <br />Z 0. • c *IH 101653 <br />o P� yA0N'ed iht� <br />Ndei��¢�y Off: <br />�i o ' 6j1c N' .• <br />STATE <br />Sworn Statement of Disclosure of Relationships - 00452-2 <br />FnPublic Works\ENGINEERING DIVISION PROJECTS\2030 Tax Collector Office Expan=_ion Bldg B\1-Admin\Bids\Bid Documents\Master Contract Documents\DIV 0-2—Bidding Documents - <br />20201002.docx <br />