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IRC -1639
<br />SECTION 00452 — Sworn Statement on Disclosure of Relationships
<br />SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, ON DISCLOSURE OF
<br />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. 2022028
<br />2.
<br />3.
<br />4.
<br />5.
<br />A
<br />for 69TH STREET FROM 66TH AVENUE TO SR51US-7 RESURFACING
<br />This sworn statement is submitted by:
<br />whose business address is:
<br />Timothy Rose Contracting, Inc.
<br />(Name of entity submitting Statement)
<br />825 8th Street, Vero Beach, FL 32962
<br />My name is Zachary Rose
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is Vice President
<br />I 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 />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 />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 />Sworn Statement of Disclosure of Relationships - 00452-1
<br />FVub is WorksIENGINEERING DIVISION PROJECTSM3969th Street 66th Avenue to US -1 Resurfacing (SC0P)\1-Admin%BJds1B1d Documents - AdvertisementlDIV 0-1—Bidding Documents -
<br />20210824.docx
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