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SECTION 00452 - Sworn Statement under Sect. 105.08 Indian River County Code on
<br />Disclosure of Relationships
<br />THIS FORM
<br />MUST BE
<br />SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
<br />OR OTHER
<br />OFFICER
<br />AUTHORIZED TO ADMINISTER OATHS.
<br />This sworn statement is submitted with Bid, Proposal or Contract No. 9705B for
<br />Oslo Road (CR606) / Lateral "J" Canal Bridge Replacement
<br />1. This sworn statement is submitted by: uiCAo eapd tMF_ WC
<br />(Name of entity submitting sworn statement)
<br />whose business address is: &SO Sr SLA-PrEiZ sT .
<br /><�zuA4T, FL aqqC14 and
<br />(if applicable) its Federal Employer Identification Number (FEIN) is 69-a9024-87
<br />(If the entity has noEIN, include the Social Security Number of the individual signing this
<br />sworn statement pjii� ).
<br />2. My name is ley IN V..- . LUL KS
<br />(Please print name of individual signing)
<br />and my relationship to the entity named above is &ES1DEA1T
<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. 1 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-in-law, brother-in-law, 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 />00452 . Disclosure of Relationships
<br />00452. 1
<br />FAPubllc Works\Capltal Projects\Oslo Road Lateral J\BID DOCUMENTS\00452 - Disclosure of Relatlonships.doc Rev. 05/01
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