|
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 /> r.
<br /> This swom statement is submitted with Bid , Proposal or Contract No . 2.129 for KiTCHING
<br /> STATION TRAILHEAD .
<br /> 1 . This swom statement is submitted by: 12T�I C© hlS'tjZUL`l'tOt� , � r�1L •
<br /> (Name of entity submitting swom s tement)
<br /> whose business address is : i�J1 IM ) i Amt �l J � 4�1� — x� ry7A
<br /> 9D and
<br /> (if applicable) its Federal Employer Identification Number (his . 1 t
<br /> ' t ( If the entity has no FEIN , include the Social Security Number of the individual, signing this
<br /> swom statement ).
<br /> 2. My name is RItt. b4(2, 'rt-1-
<br /> -i (Please print name of individual signing)
<br /> 3 and my relationship to the entity named above is 49295ipgt4 "
<br /> 3 3. 1 understand that an "affiliate" as defined in Section 105 . 08, Indian River County Code,
<br /> means :The term . "affiliate " includes those officers, directors, executives, partners,
<br /> Y_
<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 /> G Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br /> cousin, nephew, niece, husband, wife, father-in-law; mother-in-
<br /> law, daughter-in-law, son4n4aw, brother-in-law, sister4n4aw,
<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 1 have marked :below is true in
<br /> relation to the entity submitting this swom statement. [Piease indicate which statement
<br /> applies.]
<br /> Neither the entity submitting this swom 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 swom 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 /> 021940452 - Disclosure of Relationships
<br /> 00452 - 1
<br /> F:1t:n01neehnplWtal Pm"%0219.10tching SteOan Trallhead1021910tch1np*Conhad Does10219MM - Disdosure of ReInUamhlps.doa Rev. 0501
<br />
|