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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 s ate en i su'led with RFP No. 200 1 for <br /> CniC4 UA r, S <br /> 2 . This sworn statement is submitted by: 'Ab <br /> J (Name of entity submitting Statement) <br /> �whho7 <br /> se business address is: <br /> and <br /> (if applicable) <br /> its Federal Employer Identification Number (FEIN ) is =j �5ESo t <br /> (If the entity has no FEIN , include the Social Security Number of the individual signing <br /> this sworn statement <br /> 3 . My name is _ t `7 C� QI �.11✓tQ <br /> (Please print name of individual signing) <br /> and my relationship to the entity named above is <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 /> XIII <br />