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<br />fiSWORN STATEMENT UDDER ,SECTIOiV
<br />INDIAN MER COUNTY CQDE
<br />l QLQ.5URE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br />OFFICER AUTHORIZED TO ADMINISTER OATHS,
<br />1. This sworn statement is submitted with Bid No. OU
<br />7_. This swem statement is submitted by:_Ju,,• , Ac
<br />\_C, C__ �- r- _whose
<br />business address is. 1940 _ku %j to�>_L\z4# (if applicable)its Federal
<br />Employer Identification Number (FEIN) is . M- LL 't `�91 . 4if il�e entity
<br />has no FEIN, include the Social Security number of the individual signing this
<br />sworn statement )
<br />3. My name is W + a 1�k, 5 S,)l- �- - -= and my relationship
<br />to the entity named above is -%� 4- S'%. 5� i r-
<br />4. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County
<br />Corte, means:
<br />The term "affiliate" includes those officers, directors, executives, partners,
<br />shareholders, employees, membors, and agents who are active in the
<br />management of the entity -
<br />5. 1 understand that the relationship with a County Commissioner or County employee
<br />that must be disclosed is as follows:
<br />Father, mother, am, daughter, brothor, sister, uncle, aunt, first cousin, nephew,
<br />niece, husband, wife, father-in-law, mother -In -lave, daughter-in-law, son-in-law,
<br />brother-in-law, sistor-inflaw, stepfather. stepmther, stepson, stepdaughter.
<br />stepbrother', stepsister, half brother, hall sister, grandparent or grandchild.
<br />5. Based on information and belief, the statement which I have marked bellow 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, members, or agents who are active
<br />in management of the entity, have any relationships as defined in Section 105.08,
<br />Indian River County Cotte, with any County Commissioner or County employee.
<br />The entity submitting this sworn statement, or one or more of the officers, directors,
<br />executives, partners, shareholders, employees, members, or agents who are active
<br />in management of the entity have the following relationships with a County
<br />Commissioner or County employaw
<br />STATEMENT ON DLSCLQSURF
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