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<br />SII I/951doc/discloce.daclblf
<br />gl SWORN STATFMFNT I NDERSECTION
<br />I
<br />INDIAN R OF a RELATIONSHIPS
<br />a THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />AUTHORIZED TO ADMINISTER OATHS,
<br />1. This sworn statement is submitted with Bid. Proposal or Contract No. 1112(0
<br />q
<br />r f _LUJ i I loin Stree;i- i 196, u.n QL`P,JeD-e�
<br />' 2. Ibis sworn statement is submitted by:
<br />Sher yso'^ su�f��
<br />"" 'o co'Tnr- (Nameorenary fubirrour swim
<br />whoa business adds., is: 'p 1 1
<br />is 111911 SIa9 Jan.UUre slt--YY�IQ/\"FiJ Lf)/1_ undlifspplicable)
<br />its Federal Employer Identification Number(FEW)is 5g-IbL1:1C9K9
<br />(If Ne endryhas mo FEW, include the Social Security Number of Nc individual signing this swam statement
<br />S ). My name is !� "GhG,-(A S h 1
<br />tvbsse over name orla irmualalan{n., L
<br />y and my relationship m Ne emitY named above is YI"'P.:� f �Y.lh 1
<br />4. I undersand Nat.n "affiiate" as delved in Section IOS.08, Indian River County Cade, means: The ectm
<br />"affiliate" Ncludes Nose oflcers, dvecmm, execntives, partners, shareholders, employees, mcmbas, and r,mr
<br />who are active in the management of Ne entity,
<br />5. 1..defsund Nat one relationship with a Cowry Commisstoner -Cou try employee that mos be disclosed is
<br />as follows:
<br />Father.mothe'. son, daughter, bmNer,sister, uncle, mm, first cousin, .,,new, niece,
<br />husband, wife, father-inrlaw, mother in law. daughter-in-law, son in -taw, broNenN.
<br />law, sicrnin-law, stepfather, ampmmli , stepson, stepdaughter, sapbrumer,
<br />stepsister, halfbmWer, half sister, grandparent or grandchild.
<br />6. Based an hsfumnam. and belief, On, statement which I have marked below is we in relation to the entity
<br />I submitting Nis swam statement.[Please indicate which simement applies.]
<br />� Neither the entity submitting this swans slmement, nor any officers. directors, executives, palmers,
<br />sharehoidefs, employees, member, of agents who am active in management of Is entity, have any relation.
<br />ships as defined in Section 105.08, Indian River County Code, with any County Commirioner of Caunry
<br />employee.
<br />The emit, submitting Nis swam statement, or one or mom of'be offers. directors. cxecudwa, prom¢.,
<br />a'
<br />shareholders, employees, members, or.gents ,he arc active in management of the only have the following
<br />relationships with a County Commissioner or County employee
<br />ra.... of AMI, n/fn.
<br />etyfnm..sasicax Penslu,
<br />L
<br />Nauru
<br />Fatov flmplor,
<br />L DOR-2
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