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s �,o st5 �� r o P •opertV� i� afl age o entCorp. <br />SECTION 00452 <br />SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER COUNTY CODE, <br />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 />1. This sworn statement MUST be submitted with Bid, Proposal or Contract No. 2015036 <br />for 87th Street and 91' Avenue Sidewalk Tmprovements. <br />2. This sworn statement is submitted by: Kerns Construction & Property 1ilan<geinent Corp. <br />ame of entity submitting Statement) <br />whose business address is: <br />1217 Delaware Avneue, Fort Pierce, FL. 34950 <br />My name is Dauiei L. , iu:,ch\\ ecl- <br />(Please print name of individual signing) <br />and my relationship to the entity named above is Vi c <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 />5. I understand that the relationship with a County Commissioner or County employee that must be <br />disclosed as follows: <br />Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, <br />father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, stepfather, <br />stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or <br />grandchild. <br />6. Based on information and belief, the statement, which I have marked below, is true in relation to the <br />entity submitting this sworn statement. [Please indicate which statement applies.] <br />Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, <br />shareholders, employees, members, or agents who are active in management of the entity, have any <br />relationships as defined in section 105.08, Indian River County Code, with any County Commissioner <br />or County employee. <br />00452-1 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1205-Vero Lake Estates Swk-87th St_101st Ave to CR510 (LAP)\Admim\bid <br />