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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 . <br /> Page 25 of 40 <br />