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<br />f May 25, 1999
<br />5111f95(doc/disclose.doc)blf
<br />i-WQRN S7A' EN1ENT UNDER SECTION 105.08
<br />1NAIAN 1rZ[VI Ii 1'Y ((,i1JC�f)N 1)1SC L()SUItI+�iF RELA'T'IONS111['
<br />THIS FORM MUST BE SIGNED IN THE PlIESENCE OF A NO'T'ARY PUBLIC OR OTHER
<br />OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />4. This sworn statement is submitted with Bid, Proposal or Contract No. 9062 for
<br />DQJ ALD MACDONALD 1'A tIC IMPROVEMENT"s
<br />2. Thus swam statement is submitted by;
<br />(Name of entity submitting stvom
<br />whale business address is; statement)
<br />-. t' bq- > jj� S-7 ( V 9,tC)� e l_ If L. -' Z_tm and (ir applicable)
<br />its Federal Employer Identification Number (FEIN) is T G 7
<br />(If the entity has no I iIN, include the Social Securit Nit NNumber ofthe the individual signing t us sworn
<br />statement )
<br />3. My name is \its 1 4 n ` , 0
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is t
<br />4. 1 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, entployees,
<br />members, and agents who are active in the managentent of the entity.
<br />5. I understand that the relationship with a County Commissioner or County ernployce that must be
<br />disclosed is as hollows:
<br />Fattier, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece,
<br />husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law,
<br />sister-in-law stept'afher' steprnoflle:, �tei.,surt, stcP(It fighter, sieirbruthur, stepsister, halt
<br />brother, half sister, grandparent or grandchild.
<br />6. Based on information and belief, the statement which I have marked below is true in relation to the
<br />entity submitting this sworn statement. (Please indicate which statement applies.]
<br />Neither the entity submitting this sworn statement, nor any onicei s, directors, executives, partners,
<br />shareholders, employees, members, or agents who arc active in imrtagemernt of the entity, have any
<br />relationships as defined in Section 105.08, Indian River County Code, with any County
<br />Commissioner or County employee.
<br />The entity submitting this sworn staternent, or one or ,,are of the officers, directors, executives,
<br />Me
<br />shareholders, employees, members, or agents who are active in management of the entily
<br />have the following relationships with a Cuttnty Commissioner or County employee;
<br />
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