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SWORN STATEMENT UNDER SECTION 105.089 INDIAN RIVER COUNTY
<br /> CODE, ON DISCLOSURE OF RELATIONSHIPS 11
<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 . 2007075
<br /> for Food Concession Services for the Sandridge Golf Club
<br /> 2 . This sworn statement is submitted by: R P.2ii- AJoA,' .NR �1
<br /> fl PIZIL ,JeAgM .4 ✓
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> I L* 5 y 9 p z /4V& # 303 l eQ6 /3E.gCAI 9la 4� and (if
<br /> applicable) its Federal Employer Identification Number (FEIN) is S5 a ? oo..,2 9 5 (If the
<br /> entity has no FEIN, include the Social Security Number of the individual signing this sworn
<br /> \r statement V & l - 9 9 - oa / o )
<br /> 3 . M_v name is 41;1ll1G. NORin ,* A✓
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is S 6 4 /'
<br /> 4 . I understand that an "affiliate" as defined in Section 105 .08, Indian River County Code, means:
<br /> The term "affiliate" includes those officers, directors, executives, partners, shareholders,
<br /> employees, members, and agents who are active in the management of the entity .
<br /> 5 . 1 understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband,
<br /> wife, father- in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister- in-law,
<br /> stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
<br /> grandparent, or grandchild.
<br /> 6. Based on information and belief, the statement, which I have marked below, is true in relation to the
<br /> entity
<br /> TAW
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