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Attachment A
<br />IRC -15056 RFQ-CCNA 2022 FINAL
<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. 2022072
<br />for Construction Engineering and Inspection (CEI) Services for IRC -1505B — 66th AVE From 69th
<br />St to CR-510/85th St.
<br />2. This sworn statement is submitted by:
<br />(Name of entity submitting Statement)
<br />whose business address is:
<br />and its Federal Employer Identification Number (FEIN) is
<br />My name is
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is
<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,
<br />employees, 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
<br />be disclosed as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband,
<br />wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law,
<br />stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
<br />grandparent, or grandchild.
<br />Based on information and belief, the statement, which I have marked below, is true in relation
<br />to the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />Neither the entity submitting this sworn statement, nor any officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in management of the
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