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SWORN STATEMENT UNDER SECTION 105. 08
<br /> INDIAN RIVER COUNTY CODE ON DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
<br /> OFFICER AUTHORIZED TO ADMINISTER OATHS .
<br /> This sworn statement is submitted with Bid, Proposal or Contract No . 6031 for INDIAN RIVER
<br /> COUNTY MITIGATION REEF PROJECT - SHORELINE SECTORS I & 2 (AMBERSAND
<br /> BEACH)
<br /> 1 . This sworn statement is submitted by
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is :
<br /> and (if applicable)
<br /> its Federal Employer Identification Number (FEIN) is
<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 /> 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 . I understand that the relationship with a County Commissioner or County employee that must
<br /> be disclosed is as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew,
<br /> niece, husband, wife, father-in -law, mother-in -law, daughter-in-law, son- in -law,
<br /> brother-in-law, sister-in -law, stepfather, stepmother, stepson, stepdaughter, step-
<br /> brother, 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 relation
<br /> to the entity submitting this sworn statement. [Please indicate which statement 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 /> DISCLOSURE OF RELATIONSHIPS
<br /> SS- 1
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