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<br /> SECTION 00452 - Sworn Statement under Sect. 105 .08 Indian River County Code on
<br /> Disclosure of Relationships
<br /> r
<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 Bid , Proposal or Contract No . 0209 for 41h Street /
<br /> ,. Cooch Ditch Bridge Replacement.
<br /> 1 . This sworn statement is submitted by: 1Yhbp
<br /> r _(Name f e sub itting sworn tatement)
<br /> Vyvhose b iness address is : � t 4 `p
<br /> g � l 3 � 9Cc2 and
<br /> (If applicable) its Federal Employer Identification Number (FEIN) is 5- 629 y 01Wf2
<br /> r (If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement 1 � ,
<br /> .. 2 . My name is �Tlrno ±► �1 �.
<br /> (Please print name afipdividual signing)
<br /> and my relationship to the entity named above is Is yk I 4.s.3ywsr
<br /> r 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 /> r 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 /> r 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 /> 1ecu
<br /> es.Neither the entity submitting this sworn statement, nor any officers , directors ,
<br /> tives , 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 /> 0209-00452 - Disclosure of Relationships.doc
<br /> 00452 - 1
<br /> FaEngineering\Capital prgeclsW209<th Street Bridge Over Coots MchW2094h Street Bridge Over Cooch 07-20.0510209-00452 - Disclosure of RelatiwshipsAo ev.
<br />� 05107
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