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L <br />r <br />a <br />IN THIS FOP -H HUST BE SIGNED To�7WHIHIaTER�� THBUTT�tY PUBLIC <br />aR OTHER Ory <br />y, This sworn statement is submitted wit Proposal <br />or Contract t7o. <br />g61-1 for <br />Z. This sworn statement is submit ed by: <br />hl..� : ,vo .it�. f `" . _. nrn scaeemene <br />VC1`' identif ication <br />and (if applicable) its Federal Employer <br />Number -f ;Z.� } (if the entity has no <br />(FEIN) zs ° e Skog a 9 5ecuri yJ+ Number <br />a£ tris individual ) <br />FEIN, inclu e <br />signing this sworn s�—11 <br />n�1 <br />3. My name is ease print name or Ln �v� ua sxgnxngl <br />p <br />tit named above is „�� <br />and my relationship to the en y <br />:1, <br />understand that an "af f ode, means; def fined in section <br />a. Indian Ricer County Cade, means: <br />]a5.d8r directors, <br />The term "affiliate" includes those sharehoiders employees, members, <br />eXecutives, partners, agement of the <br />and agents who <br />are active in the man <br />entity with a County <br />5. I tnder'stand_that+the relationship <br />Cota�uissiorser or County employee that must be disclosed is as <br />follows: brother, sister. uncle, <br />Fattaer� mother, son, daughter, father - <br />aunt. hist cousin. nephew. niece. husbason-in-law, <br />in-law, m,,ther-in-law, daughter-in-law, <br />brother-in-law, sister -in -taw, stepfather, stepmother, <br />stepson, stepdaughter, stepbrother, stepsister, half <br />stepson'herp half sister, grandparent or grandchild. <br />