Laserfiche WebLink
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 />Name of County Commissioner <br />or employee <br />STATE OF FJ` <br />COUNTY OF j- 1 a `g 91JCS r <br />Relationship <br />(Signature) <br />(Date) <br />Sworn to (or affirmed) and subscribed before me by means of 1LYphysical presence or Cl online notarization, <br />this 15 day of Fe --b 20_a -A,, by Wi 14cz J- (name of person <br />making statement). <br />(Signature of Notary Public - State of Florida) <br />(Print, Type, or Stamp Commissioned Name of Notary Public) <br />591"E%%' <br />JOHN T. DALE <br />who is personally known to me Or ❑who has produced' Notary Public - State of Floridi <br />as identification.a` Commission p GG 136994 <br />My Comm. Expires Jul f0, 2023 <br />Bonded through National Notary Assn. <br />END OF SECTION <br />00452.2 <br />FAPublic Works\ENGINEERING DIVISION PROJECTS\2020 JRTC Ticket Orice Renovations\t-Admin\Bids\Bld Documents\Rebid\00452 -Disclosure <br />of Relationships.doc <br />