|
SECTION 00452
<br />SWORN STATEMENT UNDER SECTION 105.08, 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. 202.2026
<br />for A KIE ROBINSON TRAINING COMPLEX TICKET OFFICE BUILDING RENOVATIONS
<br />2. This sworn statement is submitted by:
<br />whose business address is
<br />DE LA HOZ BUILDERS, INC.
<br />(Name of entity submitting Statement)
<br />258 Del Monte Rd, Sebastian, FL 32958
<br />3. My name is HILDA DE LA HOZ
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is President
<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 />I 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
<br />or County employee.
<br />00452.7
<br />FAPublic WorksIENGINEERING DIVISION PROJECTS12020 JRTC Ticket office Renovatlonski-AdminlBids\Bid Documents Rebid\00452 • Disclosure
<br />of Relationships.doc
<br />
|