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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
<br /> OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS .
<br /> 1 . This sworn statement is submitted with RFP No . 2007043 for St. Peter's Boys
<br /> Development & Training Institute.
<br /> 2. This sworn statement is submitted by: St. Peter's Human Services.
<br /> (Name of entity submitting Statement)
<br /> whose business address is:
<br /> 4250 38'" Avenue, Vero Beach , FI 32967 and
<br /> (if applicable)
<br /> its Federal Employer Identification Number (FEIN) is 31 -1480633
<br /> (If the entity has no FEIN , include the Social Security Number of the individual signing
<br /> this sworn s en
<br /> 3. My a is ndrew Jefferson
<br /> (Please pri name of individual signing)
<br /> and my relationship to the entity named above is President .
<br /> 4. 1 understand that an "affiliate" as defined in Section 105 . 08, Indian River County
<br /> 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
<br /> that must be disclosed as follows:
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin ,
<br /> nephew, niece, husband , wife, father-in-law, mother-in-law, daughter-
<br /> in-law, son-in-law, brother-in-law, sister-in-law, stepfather, stepmother,
<br /> 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
<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
<br /> XIII
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