|
Exhibit B . 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 /> This sworn statement is submitted with that certain Agreement for Donation of Surplus County .
<br /> Owned Lands .
<br /> 1 . This sworn statement is submitted by : CdA IT IDN Fol ATi' 4INA (6LF G�o1�tfS , 1C
<br /> ( Name of entity submitting sworn statement)
<br /> whose business address is : � 1 11 l W b ; A N ROJEIQ PdLV O . , 5u LT C 301
<br /> V GYto t3E ACN , fit_ 324[00 and
<br /> ( if applicable ) its Federal Employer Identification Number ( FEIN ) is g4rOZ1
<br /> 2 . My name is THOW, We I 1 t 12 N C 'r
<br /> ( Please print name of individual signing )
<br /> and my relationship to the entity named above is FbA kb- G !-{ 6I R
<br /> 3 . 1 understand that an " affiliate " as defined in Section 105 . 08 , Indian River County Code ,
<br /> means :
<br /> The term "affiliate " includes those officers, directors, executives, partners,
<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 /> 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, son-in-law, brother-in -law, sister-in-law,
<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 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 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 sworn 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 />
|