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IRC -1639 <br />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 Name of County Commissioner Relationship <br />or entity or employee <br />N/A <br />STATE OF Florida <br />COUNTY OF <br />Indian River <br />(Signature) <br />3/31/22 <br />(Date) <br />Sworn to (or affirmed) and subscribed before me by means of ® physical presence or ❑ online <br />notarization, this 31st day of March 2022, by Zachary Rose <br />(name of person making statement). � n �} <br />Rwo <br />NotWy Public Stale of Florida (Signature of Notary Public - State of Florida) <br />NK Stall 8 Best Print, Type, or Stam Commissioned Name of Nota Public <br />My Commsmon HH 078488( P ry } <br />Expms 0 210 512 02 5 persona y nown o me or ❑ who has produced <br />as identification. <br />* * END OF SECTION * * <br />Sworn Statement of Disclosure of Relationships - 00452-2 <br />F:1Public Works\ENGINEERING DIVISION PROJECTS\1639 69th Street 66th Avenue to US -1 Resurfacing (SCOP)11-Adndn\51ds'8d Documents-AdvertisementUV 0_t_Bidding Documents - <br />20210824.docx <br />