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SWORN STATEMENT UNDER SECTION 105 . 08, INDIAN RIVER COUNTY CODE, ON
<br /> 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 /> 1 . This sworn statement is submitted with Bid, Proposal or Contract No . 6080 for
<br /> INDIAN RIVER COUNTY
<br /> 2 . This sworn statement is submitted by : E . J . BRENEMAN L . P .
<br /> (Name of entity submitting Statement)
<br /> whose business address is :
<br /> 1117 SNYDER ROAD , WEST LAWN , PA 19609 and (if
<br /> applicable) its Federal Employer Identification Number (FEIN) is 234430672 (If the entityhas
<br /> no FEIN, include the Social Security Number of the individual signing this sworn statement
<br /> . )
<br /> 3 . My name is PHILIP D . WAGNER
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is PARTNER
<br /> 4 . I understand that an "affiliate" as defined in Section 105 . 08 , Indian River County Code,
<br /> means : The term "affiliate" includes those officers, directors, executives , partners,
<br /> shareholders, employees, members , and agents who are active in the management of the
<br /> entity.
<br /> 5 . I understand that the relationship with a County Commissioner or County employee that must
<br /> be disclosed 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, half sister, grandparent, or grandchild.
<br /> 6 . Based on information and belief, the statement, which I have marked below, is true in relation
<br /> to the entity submitting this sworn statement. [Please indicate which statement 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 River
<br /> 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 in
<br /> management of the entity have the following relationships with a County Commissioner or
<br /> County employee :
<br /> FP.Purchasing\Bids\2003 -2004 FY (6000)\6080 Resurfacing on CR512 from SR 60 to Felismere Farms\6080 Bid Documcnt.doc
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