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4 <br />40 <br />• <br />i <br />i 8tkOM STATEMM L' ")ER SRCTION 105.09 <br />1� nMIM RIVZit COUNTY CODE 4 ON DISCLOSURE OF R'ELA'TIONSHIPS <br />Tglg i`Dlpif MUST BE SIGuzo IN TEM PRESENCE OF A NOTARY PUBLIC OR <br />?-TgMR OFFICER AUTHORIZED TO ADb=ISTER OATHS. <br />1. This sworn statement is submitted with RFP No.y for <br />2. This sworn statement is submitted by: <br />Tri -Sure Corporation <br />(Name of entity submitting sworn statement) <br />3. <br />whose business address is: <br />F. 0. Box 653, Auburndale, F1 33833 and (If <br />applicable ) its Federal Employer Identification Number <br />(FEIN) ].5591498145 ri (if the'entity has no FEIN, include <br />f <br />the Social Security Number of the individual signing this <br />sworn statement 1 <br />My name is ,Tames 11. Chambers and my <br />(Print name of individual signing) <br />relationship to the entity named above is president <br />4. I understand that an "affiliate" as defined in Section <br />105.QB, Indian River County Code, means: <br />The term "affiliate" includes those officers, directors, <br />executives, partners, shareholders, employees, members, and <br />agents who are active in the management of the entity. <br />5. I understand that the relationship with a County <br />Commissioner or County employee must be disclosed as <br />follows: <br />Father, mother, son, daughter, brother, sister, uncle, <br />aunt, first cousin, nephew, niece, husband, wife, father-in- <br />law, mother -in --law, son-in-law, brother-in-law, sister-in- <br />law, stepfather, stepmother, stepson, stepdaughter, <br />stepbrother, stepsister, half brother, half sister, <br />grandparent or grandchild. <br />(lased on information and belief, the statement which I have <br />marked below is true in gelation to the entity submitting <br />�. <br />04310 -aro <br />