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C-1 511 t FAdxldiadr+se.doc)blf S.WQRLA .I� 1 ENTU � M359TID '[45.08. IN_QLAN—RUE C 0 U N TLY. C -M O" LS= 9K511U THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 1, This sworn statement is submitted with Bid foto. 9220 -- 2. This sworn statement is submitted by:=A`�4_s'•l �� r1�. address is: _ t J _. and 4if aplicablejits Federal Employer Identification ,. L Number fF I iris i rI i4 4'i 17�` t f'tl the entity has no FEIN, include the Social 4 N1 Security Number of the individual signing this sworn statement 3. My name is ` Y)oi �C c � L _Vc1V and my relationship to the entity named above is '1` ti . ' � ` ff t r ' 11(41('t 4. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County Code, Ll means- The term "affiliate" includes those officers, diredors, executives, partners, shareholders, employees. members and agents who are active in the management of the entity 5. I understand that the relationship with a County Commissioner of County employee that must be disclosed is as follows: Father, mother, son. daughter, brother, sister. Uncle, aunt, first cousin, nephew, niece, husband, wife, father,rn•fan rnolher.in.lav daughter-in-law, son-in-law. brother -+n -law. srster-rn-larrr. Stepfather steprncther stepson, stepdaughter stepbrother stepsrslef. half brother, half sister, grandparent or grandchild 5. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. [Please indicate which slaterrfent applies.) I/Neither the entity submitting this sworn statement, nor any officers, directors„ executives, ..^^rs, siiarelWdefs, Gin lU ues, inumbers, or agents who are actsve Irl management �......^� Ia y of the entity, have any relationships as defined in Section 105,08, Indian River County Code, with any County Commissioner or County employee. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in Management of the entity have the foiiowineg relationships vnth a County Commissioner or County employee. STATEMENT ON DISCLOSURE timl