|
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 Contract No. 0386 for the Pelican
<br /> Island National Wildlife Refuge Upland Restoration ,
<br /> ' 1 . This sworn statement is submitted by: Sitewerks , Inc .
<br /> �- (Name of end submhdn swom statement)
<br /> whose business address *S : 4045 43rd Ave. - Vero Beach , FL 3296
<br /> '
<br /> ... ( if applicable) its Federal Employer Identification Number (FEIN) is and
<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 Jeff Brewster
<br /> ' (Pease Exmt name Vice President ,
<br /> and my relationship to the entity named above is
<br /> 3 . 1 understand that an "affiliate" as defined in Section 105 . 08 , Indian River County Code,
<br /> means .
<br /> The term "affillate " includes those officers, directors, executives, partners,
<br /> shareholders, employees, members, and agents who are active in the management
<br /> ' of the entity.
<br /> —
<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, father4n-law, mother-in-
<br /> law, daughter4n-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 /> X 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 /> V
<br /> n management of the entity have the following relationships with a County
<br /> Commissioner or County employee:
<br /> t `
<br />
|