|
IRC -1707
<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 AUTHORIZED TO
<br />ADMINISTER OATHS.
<br />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2022046
<br />for INDIAN RIVER BOULEVARD RESURFACING FROM 53RD STREET TO THE MERRILL
<br />BARBER BRIDGE
<br />2. This sworn statement is submitted by:
<br />C. W. Roberts Contracting, Inc.
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />8530 SW Jayme Way, Palm City, FL 34990
<br />3. My name is Daniel Hoyt
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is Area Manager
<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 />5. 1 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 />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 />Sworn Statement of Disclosure of Relationships - 00452-1
<br />FAPublic VJorks\ENGINEER]NG DIVISION PROJECTSU 707 Indian River Blvd Merrill Barber Bridge to 53rc St Resurfacing (SCCP)11-Admin\8id Documents\Bid DOCUmentslDIV O 1 Bid and Contract
<br />Doc—IRC-1707 docx
<br />
|