|
SECTION 00452 - Sworn Statement under Sect. 105.08 Indian River County Code on
<br /> ! Disclosure of Relationships
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
<br /> OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS,
<br /> This sworn statement is submitted with Bid , Proposal or Project No . 0399 for NORTH
<br /> COUNTY REGIONAL PARK, PHASE 2.
<br /> 1 . This sworn statement is submitted by: 412n4 Gok5fWcTloA W c.
<br /> 1J (Name of entity submitting swam statement)
<br /> whose business address is : I �[ I'lJAy> 1al4 121JF2 egooyp &mZo2A
<br /> *Ro 4!:;oAc4t , VL� 3Z4C,o o and
<br /> t (if applicable) its Federal Employer Identification Number (FEIN) is 51v 193/ boy
<br /> (if the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement ).
<br /> 2. My name is F::;; At2"T4
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above isES + oF'p-x'r
<br /> 3 . 1 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,
<br /> shareholders, employees, members, and agents who are active in the management
<br /> of the entity.
<br /> 4 . I understand that the relationship with a County Commissioner or County employee that
<br /> must be disclosed is as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br /> cousin, nephew, niece, husband, wife, father-in-law, mother-in-
<br /> law, daughter-in-law, son-ln-law, brother4n4aw, sister-in-law,
<br /> stepfather, stepmother, stepson, stepdaughter, stepbrother,
<br /> stepsister, half brother, half sister, grandparent or grandchild.
<br /> 5 . 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 /> 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 /> 0399-00452 - Disclosure of Relationships.doc
<br /> 00452 - 1
<br /> ei FAEnglneeringcapital Pro)eds\0399 North County Regional Park, Phase IM399 Contract DocsW399-00452 - Disclosure or Relatlonships.doc Rev. 05101
<br />
|