|
40
<br />E-1
<br />0
<br />5111195(docldisClose-doc )
<br />i W RN $_TATEIVI NT UN__ NER $ CTI N 105.08
<br />j INDIAN RlVFR QQ11MTV C of
<br />N O1_$CLi IRS CSF RI;L—I NSHIPS
<br />THIS FORM MUST BE SIGNE=D IN THE PRESENCE -
<br />CC OF A NOTARY PUBLIC OR OTHEE
<br />f OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />{ 1. This sworn statement is submitted with Bid, Proposal or Contract No., `(cl- a -7`1 for
<br />r . ri r. •.' '.:� -- � ' , • , s � � • � l . i ,
<br />A. Yl. l'�f`'l
<br />2.. This sworn statement is submitted by: t -o-r(
<br />N hosebusinesG
<br />address is:t1'st r t ti , : , and (if applicabie)its Federal Employer Identificatiors
<br />Number (FEIN) is ' t '; Y. • (If the entity has no FEIN, include the Social
<br />Security Number of the individual signing this sworn statement I
<br />S. My name is 1 . t " •, t - S ,t,. „ ; and my relationship
<br />to the entity named above is ' ` Is r : ,� i . , t ) I - �,. � ,t 'i
<br />4. 1 understand that an "affiliate" as defined in Section 905.08, Indian, River County Code,
<br />means:
<br />The term "afrow," irio.r,i_ tr,o�e officers, directors, executives, partners, shareholders,
<br />employees, members, acrd agents who are active in the management of the entity.
<br />5. 1 understand that the relationship with a County Commissioner
<br />or County employee that
<br />must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, rust cousin, nephew, niece,
<br />a
<br />husband, wife, father -in -raw, mother-int-iaw, daughter-in-law, son-in-law, brother-in-law,
<br />sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half
<br />brother, hall sister, grandparent or grandchild
<br />r
<br />5. Based on information and belief, the statement which I have marked below is true in
<br />relation to the entity submitting this sworn statement. (Please indicate which statement
<br />applies.?
<br />6'
<br />X— Neither the entity submitting this sworn statement, nor any officers, directors, executives,
<br />' partners, shareholders, employees, members, or agents who are active in management
<br />t' of the entity, have aiiy relationships as defined in Section 105.08, Indian River County
<br />j: Code, with any County Commissioner or County employee.
<br />The entity submitting this sworn statement, or one or more of the officurq, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active in
<br />management of the entity have the following relationships with a Courfy Commissioner or
<br />County employee:
<br />
|