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4W <br />r <br />r� <br />SWORN UNDER SECTION 105.08 <br />Iim AIVER CC]Uti`1'lC CDDE ON DISCLOSupE OF PYJAATIONSHXPS <br />TRIS FORM MUST BE SIGIM IN THE i'RESE,HCB OF A NOTARY PUBLIC OR <br />OTM OFFICER AUTHORIZED TO ADMrNISTER OATHS. <br />} , This sworn statement is submitted with RFP No._M7i__ for <br />`ebas,t,.�an Hater AS�� "�' Phase 2C <br />2. This sworn statement is submitted by: <br />Treasure Coast Contractiing, Inc --- <br />T- (Name of entity submitting sworn statement) <br />whose business address is: <br />p.O. Box 650249, 6290 Old Pixie flay., Vern Y}each, FL 32965 and (If <br />applicable ) its federal Employer Identification Number <br />(FEIN) is (If the entity has no 'FEIN, include <br />the Social Security Number of the individual signing this <br />sworn statement <br />3. My name is and my <br />(Print name of individual signing) <br />relationship to the entity named above is President <br />4. I understand that an "affiliate" as defined in Section <br />105.06, Indian River County Code, means: <br />The term "affiliate" includes those officers, directors, <br />SharehCldery cmployeeE, n.cmhcy.rt;, and <br />agents who are active in the management of the entity. <br />5. I understand that the relationship with a County <br />Commissioner or County employee must be disclosed as <br />follows: <br />Father, mother, son, daughter, brother, sister, uncle, <br />aunt., first cousin, nephew, niece, husband, wife, father-in- <br />law, mother-in-law, son-in-law, brother-in-law, sister-in- <br />law, stepfather, stepmother, stepson, stepdaughter, <br />stepbrother, stepsister, half brother, half; sister, <br />grandparent or grandchild. <br />6. Based on information and belief, the statement which I have <br />marked below is true in relation to the entity submitting <br />00310-11 <br />