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40'' May 25, 1999
<br />5/11/95(doc/disclose.doc)blf
<br />r SWORN STATEMENT UNDER SECTION 105.08
<br />INDIAN RIVER COUNTY CODE ON DISCLOSURE Or, RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHEROFFICERAUTHORIZEDTOADMINISTEROATHS.
<br />4. This sworn statement is submitted with Bid, Proposal or Contract No. ___ 9061 for
<br />DALE WMIBROW PARK IMPROVEMENTS
<br />2. This sworn statement is submitted by:
<br />17 CCF"}tom "r t' ^ h 4 Z (Name of entity sutnnitting sworn
<br />whose business address is: statement)
<br />5 59 D - — ST j V Q„o S.p..n l_ F I.. 3 Zq (U (o and (if applicable)
<br />its Federal Employer identification Number (FEIN) is G S - y ti 9 cl 7 4q
<br />If the entity has no.FEIN, include the Social Security Number of the individual signing this swornstatement
<br />3. My name is W
<br />Please print name of individual signing)
<br />and my relationship to the entity named above is
<br />4. 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, employees,
<br />members, and agents who are active in the management of the entity.
<br />5. I understand that the relationship with a County Commissioner or County employee that must bedisclosedisasfollows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law,
<br />sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, halfbrother, half sister, grandparent or grandchild.
<br />6. Based on information mid belief, the statement which I have marked below is true in relation to theentity submitting this sworn statement. [Please indicate which statement applies.]
<br />Neither the entity submitting this sworn statement, no any o(Iicers, directors, executives, partners,
<br />shareholders, employees, members, or agents who are active in nrartagetnent of the entity, have anyrelationshipsasdefined in Section 105.08, Indian River County Code, with any CountyCommissionerorCountyemployee.
<br />The entity submitting this sworn statement, or one or more of the officers, directors, executives,
<br />partners, shareholders, employees, members, or agents who are active in management of the entityhavethefollowingrelationshipswithaCountyCommissionerorCountyemployee:
<br />DOR-1
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