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SWORN STATEMENT UNDER SECTJON JOS.08 <br />INDIAN RIVER COUNTY CODE. ON DISCLOSURE OF RELATIONSHIPS <br />. - <br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOT ARY PUBLIC OR OTHER <br />OFFICER AUTHORIZED TO ADMTNISTER OATHS. <br />I. This sworn statement is submitted with RPF No. __ for __________ _ <br />Dixie Heights Water Assessment Project <br />2. This sworn statement is submitted by: <br />Tri-Sure Corporation <br />(Name of entity submitting sowm statement) <br />whose business address is <br />P. o. Box 653. Auburndale, Fl 33823 and <br />(If applicable) its Federal Employer Identification Number (FEIN) is59-1498145 (If <br />the enti ty has no FEIN, include the Social Security Number of the individual signing <br />this sworn statement-------------~ <br />3. My name is Jason T . Chambers and my <br />(Print name of individual signing) <br />Relationship to the entity named above is -~V~i=c=e~P~r~e=s~i=d=e=n~t ________ _ <br />4. I understand that an "affiliate" as defined in Section 105.08, Indian River County Code, <br />means: <br />T he term "affili ate" includes those officers, directors, executives, partners, shareholders, <br />employees, members, and agents who are active in the management of the entity. <br />5. I understand that the rclation~hip with a County Commissioner or County employee must <br />be disclosed as follows: <br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, <br />husband, wife, father-in-law, mother-in-law, son-in-law, brother-in-law, sister-in-law, <br />stepfather, str.pmother, stepson, stepdaughter, stepbrother, s tepsister, half brother, half <br />sister, grandparent or grandchild. <br />6. Based on infonnation and belief, the statement which I have marked below is l11Je in <br />relation to the entity submitting this sworn s tatement. (Please indicate which s tat1,;u1en t <br />applies). <br />00310-11