|
SECTION 00452 - Disclosure of Relationships
<br /> r,
<br /> THIS FORM MUST BE SIGNED JN 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
<br /> 1 . This sworn statement is submitted by: � ,rnr5i , LA
<br /> (Name of a dty su mltting sworn statement)
<br /> whose �bysiness address is : I (o (� L,1 of 6 zg xl p,, 6W NL
<br /> V f fma. and
<br /> (if applicable) its Federal Employer Identification Number (FEIN ) is (oS 4:j;kwSc):q O�L
<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
<br /> (Please print name of individual signing)
<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 "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-iri law, mother-in-
<br /> law, daughter-in-law, son-in-law, brother-in-law, sister4n4aw,
<br /> stepfafher, 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 - 1 00452 - Dlsdosure of Relatlonships.doe
<br /> F:WtllitteMUTIIITY - ENGINEERINGIWTP • North ROW RO Brine line Discharge - UCP#22001BID DOCUMENTS Nath County ROWD DOCUMENTS100452 - Disclosure of
<br /> Relationships.da; Rev. 05/01 .
<br />
|