Laserfiche WebLink
40 <br />r <br />4W <br />fi. Based on information and belief, the statement which I have marked below is true in <br />relation to the entity submitting this sworn statement. [please indicate which statement <br />applies.] <br />V/ Neither the entity submitting this sworn statement, nor any officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active in <br />management of the entity, have any relationships as defined in Section 105.08, Indian <br />River County Code, with any County Commissioner or County employee. <br />— The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents who are active <br />in management of the entity have the following relationships with a County <br />Commissioner or County employee: <br />Name of Affiliate Name of County Commissioner Relationship <br />or Entity or employee <br />[signature] <br />/,4b- <br />1/00 <br />[date] <br />STATE OF +` <br />COUNTY OF �L <br />The foregoing instrument was acknowledged before me this,2/1� day of bedzA%,6er <br />2000'by lJd,C eetmod-e2 , <br />of 51 emeA.5 {;1d moo.a De(pie- corporation, on <br />behalf of the corporation. He/Sher is personally known to me or who has produced <br />l7 tu,prs Uc A4-1, as identification. <br />NOTA)LY,PUBLIC <br />� <br />sign. <br />print: e-rN0 N. EroiOt.A <br />State of ire 4a at large f0V <br />My Commission Expires: <br />0 ASEAL <br />PALfLl A C10TOt_A, <br />No Hy PUBLlC, SrArp <br />MY 0 <br />OF PLElRIOH! <br />4"MMISSIOM EXF4REti;03f21e01 <br />