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SWORN STATEMENT UNDER SECTION 195.2 <br />INDIAN RIVER COUNTY CODE 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 />This swom statement is submitted with RPF No. for <br />025 <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. 0. Box 653, Auburndale, Florida 33823 and <br />(If applicable)its Federal Employer Identification Number(FEIN)is 59-149814X1£ <br />the entity has no FEIN, include the Social Security Number of the individual signing <br />this sworn statement <br />3. My time is Jason T. Chambers and my <br />(Print time of individual signing) <br />Relationship to the entity named above is <br />Vice President <br />I understand that an "affiliate" As defined in Section 105.08, Indian River County Code, <br />means: <br />The term "affiliate" includes those officers, directors, executives, partners, shareholders, <br />employees, members, and agents who are active in the management of the entity. <br />I understand that the relationship with a County Commissioner or County employee must <br />be disclosed As follows: <br />Father, mother, son, daughter, brother, sister, uncle, aunt, fust cousin, nephew, niece, <br />husband, wife, father-in-law, mother-in-law, son-in-law, brother-in-law, sister-in-law, <br />stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half <br />sister, grandparent or grandchild. <br />Based on information and belief, the statement which 1 have marked below is true in <br />relation w the entity submitting this sworn statement (Please indicate which statement <br />applies). <br />00330-11 <br />