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5111195 (doradls Uose.doc)bl I
<br />S- WORN STATI~T U D{ R S CTICIN 105.98,
<br />INDIMIKE R �QIl�4.L CSC}[] ,
<br />ON DISCLOSURE OF REL6T1QN41jIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC Oil OTHER
<br />OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />1. This sworn statement is submitted with Bid, Proposal or Contract No, for
<br />2. This sworn statement is submitted by: -,-c C cd(� 141 AR:,n+
<br />y
<br />des - - ..whose
<br />business address is:, t l TCgarL P;�ercc A and (if applicable)its Federal
<br />Employer Identification Nurnber (FEIN) is (If the entity
<br />has no FEIN, Include the Social Security Number of the individual signing this sworn
<br />statement )
<br />3. My name is -fes Mose- f , 'u. L 1 ��t and my relationship
<br />to the entity named above is - f'rc s - e A -t--
<br />4. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County
<br />Code, means:
<br />The term "amliate" includes those officers, directors, execullves, pattnmrs,
<br />shareholders, employees, memtrmrs,and agenlswho armaolveln ilia management
<br />of the entity.
<br />5. 1 understand that the relationship with a Counly Coinnifssioner or County employee
<br />that must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, atIM, First cousin, nephew,
<br />i rac$, Husband, wife, rather -In-law, mother -in -taw, daughter -In-law, son-in-law,
<br />brother-in-law, sister -in -lave, slepfallicr, stopmotHer, stepson, stapdaughter.
<br />stepbrother, stepsister, halt brother, half sister, ttroodparont or grandchild,
<br />5. Based on information and belief, the statement which I have maflced below is true
<br />in relation to the entity submitting this sworn statement. [Please indicate which
<br />statement applies.]
<br />Neither the entity submitting this sworn statement, nor any officers, directors,
<br />executives, partners, shareholders, employees, remembers, orafgents who are active
<br />in management of the entity, have any retationships as defined in Section 105,08,
<br />Indian River County Code, with early County Commissioner or County employee.
<br />The entity submitting this sworn statement, or one or enure of the officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active
<br />In management of the entity have the following fela'tionsliips with a County
<br />Commissioner or County employee:
<br />r:ra;rtl:;r;r c�;; n:: •�::�,tnrt;
<br />
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