|
•
<br />•
<br />40
<br />5/ 11 /95(doc/d sclose.00c)blf
<br />SWORN STATEMENT UNDER SECTION 105 08
<br />INDIAN RIVER COUNTY CODE
<br />ON DISCLOSURE 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, Proposal or Contract No..2o qP for
<br />2. This sworn statement is submitted by:
<br />w- �, rd e-6 , _7-- , whose
<br />business address is:
<br />/'r �. and (if applicable)its Federal
<br />Employer Identification umberr (rrI Si�-o vG psi 9 . (If the entity
<br />has no FEIN, include the Social Security Number of the individual signing this sworn
<br />statement )
<br />3. My name is S AW'. and my relationship
<br />to the entity named above is iA,e e - go -e std. --
<br />4. 1 understand that an "affiliate" as defined in Section 105.08, Indian River County
<br />Code, means:
<br />The term "affiliate' Includes those officers, directors, executives, partners,
<br />shareholders, employees, members, and agents who are active In the management
<br />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, son, daughter, brother, sister, uncle, aunt, first cousin, nephew,
<br />niece, husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law,
<br />brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter,
<br />stepbrother, stepsister, half brother, half sister, grandparent or grandchild.
<br />5. Based on information and belief, the statement which I have marked below 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 Code, 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 employee:
<br />STATEMENT ON DISCLOSURE
<br />SS - 1
<br />
|