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<br />SWORN STATEMENT UNDER SECTION 105.08,
<br />INDIAN RIVER COUNTY CODE ON DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER
<br />AUTHORIZED TO ADMINISTER OATHS.
<br />This sworn statement is submitted with Bid, Proposal or Contract No. #3041 for
<br />Emergencv Dune Restoration Project
<br />1. This sworn statement is submitted by: k ri i 6 m e_ [,e.t -r cL.rex a u w1 / u 0 o s i V 110 1 P
<br />(Name of entity submitting sworn statement)
<br />whose business address is: 4,,f/e feLa6t, _-v-r—oIcX 1PB Fattt,es fit. -74% 4
<br />and (if applicable)
<br />its Federal Employer Identification Number (FEIN) is -r9 --.7a 936 4 a- (If the entity has no
<br />FEIN, include the Social Security Number of the individual signing this sworn statement
<br />2. My name is s,..5 U J to M �11✓l
<br />(Please print name of individual signing)
<br />relationship to the entity named above is 4S t 1!20&1r,-
<br />4. I understand that an "affiliate" as defined in Section 105.08, Indian River County Code, means:
<br />The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees,
<br />members, and agents who are active in the management of the entity.
<br />3. I understand that the relationship with a County Commissioner or County employee that must
<br />be disclosed is as follows:
<br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece,
<br />husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law,
<br />sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half
<br />brother, halfsister, grandparent or grandchild.
<br />6. Based on information and belief, the statement which I have marked below is true in relation
<br />tt the entity submitting this sworn statement. [Please indicate which statement applies.]
<br />V 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 employee.
<br />i
<br />The tors,
<br />executive , mp-oyees, mem rs, or agen s w n
<br />L. DISCLOSURE OF RELATIONSHIPS
<br />SS 1
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