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THTS 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.^2Q5D_
<br />f6r_5haaIing_13angc_-_Elj i_dingc
<br />2. This sw'om statement is submitted by: William Glover, Inc.
<br />business address is:
<br />286 N. Babcock St. Melboume
<br />Identification Number (FEIN) is 59-2300274
<br />whose
<br />and (if applicable)its Federal Employer
<br />(If the entity has no FEIN,
<br />include the Social Security Number of the individual signing this sworn statement .)
<br />3. My name is William Glover and my relationship
<br />to the entity named above is - President
<br />4. 1 understand that an "affiliate' as defined in Section 105.O8, Indian River County Code,
<br />means:
<br />The term*afriliate" includes those ofliem. direcnxs, executives, partners, shareholders,
<br />employees, numbers, and agents who sre active in the management of the entity.
<br />5. 1 understand that the relationship with a County Commissioner or County employee that
<br />must be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece,
<br />husband, wire, father-in-law, rnothcr-in-law, daughter-in-law, wn-in4a%v, brother-in-law,
<br />sister-in-law, stepfather, stepmother, aq wn, sitpdaughter, stepbrother, stepsister, half
<br />brother, half sister, grandparent or grandchtld.
<br />5. Based on information and belief, the statement which I have marked below is tate in relation
<br />to the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />Neither the entity submitting this sworn statement, nor any officers, directors, 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 />any County Commissioner or County employes.
<br />The entity submitting (leis sworn statement, or one or more of the officers, directors,
<br />executives, partners, shareholders, ctnployees, members, or agents who are active in
<br />management of the entity have the following relationships with.. a. County Commissioner or
<br />County employee:
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