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40
<br />4M
<br />MF
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<br />�'► u ► ►1 l f► M t;
<br />I► I i !: i s I
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTfiI R
<br />I OFFICER AUTHORIZED TO ADMINISTER OATHS.
<br />i
<br />1. This sworn statement is submitted with Bid No.—J-026
<br />M
<br />for tis
<br />This sworn statement is submitted by:. William Glover, Inc.
<br />whose
<br />business address is: 263 North Badcock St„ Melbourne �td (if applicable)its Federal Employer
<br />f Identification Number (FEIN)is 597300274 (If the entity has no FEIN,
<br />i include the Social Security Number of the individual signing this swom statement .)
<br />3. My name is William Glover and my relationship
<br />1 President
<br />1 to the entity named above is ,
<br />4. I understand that an "affiliate" as defined in Section 145.05, Indian River County Code,
<br />means:
<br />The term ^affiliate" includes those officers, directors, executives, partners, shareholders,
<br />employees, members, and agents who are -five in the management orthe entity.
<br />1 S. I understand that the relationship with a County Commissioner or County employee that
<br />! must be disclosed is as follows:
<br />rather, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nepho., ...c,
<br />l husband, wire, rasher -in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law,
<br />f . sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, halt
<br />brother, half sister, grandparent or grandchild.
<br />5. Based on information and belief, the statement which I have marked below is trite in relation
<br />t to the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />Neither the entity submitting this swum statement, nor any officers, d;rectors, executives,
<br />partners, shareholders, employees, members, or agents who are active in management of the
<br />entity, have any relationships as defined in Section 105.08, Indian River County Code, with
<br />t any County Commissioner or County employee,
<br />v
<br />The entity submitting this S ot;t statcnlcttt, ur one or more of the officers, directors,
<br />1 executives, partners, shareholders, employees, members, or agents wkao are active in
<br />management of the entity have the following relationships with a County Commissioner or
<br />t County employee:
<br />STATEMENT ON DISCLOSURE
<br />
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