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SWORN STATEMENT UNDER SECTION 105.08, INDIAN RIVER
<br /> 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 /> 1 . This sworn statement is submitted with Bid, Proposal or Contract No . 2008013 for
<br /> Oslo Road Clearing, 31 " Avenue SW to 43rd Avenue and 43 d Avenue Clearing , 6th Place
<br /> SW to South Relief Canal Bridge.
<br /> 2. This sworn statement is submitted by:
<br /> name of entity submitting Statement)
<br /> 3 . whose business address is :
<br /> and (if applicable) its Federal Employer Identification Number (FEIN) is (If the
<br /> entity has no FEIN, include the Social Security Number of the individual signing this sworn
<br /> statement )
<br /> My name is
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is
<br /> 4. I understand that an "affiliate" as defined in Section 105 . 08 , Indian River County 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 . I understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband,
<br /> wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law,
<br /> stepfather, stepmother, 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 relation to
<br /> the entity submitting this sworn statement. [Please indicate which statement applies.]
<br /> Neither the entity submitting this sworn statement, nor any officers , directors, executives,
<br /> partners; shareholders, employees, members, or agents who are active in management of the
<br /> entity, have any relationships as defined in section 105 . 08 , Indian River County Code, with any
<br /> County Commissioner or County, employee .
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