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submitting this sworn statement . [ Please indicate which statement applies. ] <br /> Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, <br /> r shareholders, employees, members, or agents who are active in management of the entity, have any <br /> relationships as defined in section 105 .08, Indian River County Code, with any County <br /> Commissioner or County employee. <br /> The entity submitting this sworn statement, or one or more of the officers, directors, executives, <br /> partners, shareholders, employees, members, or agents, who are active in management of the entity <br /> have the following relationships with a County Commissioner or County employee: <br /> Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> �P <br /> // (Signature) <br /> ((Date) <br /> a <br /> STATE OF tl �- <br /> W COUNTY OF <br /> The foregoing instrument was acknowledged before me this 1 � day of �y�, 20 <br /> by P ( t 1 f It` iVI f\ who is personally known to me or who has produced <br /> Gl 1) L as identification . <br /> NOTARY PUBLIC <br /> SIGN : <br /> KI1VIBERLY S. WAGNER <br /> '"Y B�' Notary Public - State of R da <br /> � ;My COMMMM L.cpres Oct 25, 2009 PRINT: <br /> :;`fid;' Comm'ssion # DD 470054 Notary Public, State at large <br /> ,`¢0� a}d;c Bonded By National Notary assn. My Commission Expires: <br /> (Sea] ) <br /> _ Page 15 of 16 <br /> t `R <br />