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<br /> SECTION 00452 - Sworn Statement under Sect. 105.08 Indian River County Code on
<br /> 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 /> r This sworn statement is submitted with Bid , Proposal or Contract No . 3, 00 2 0X7f0r
<br /> INDIAN RIVER DRIVE SOUTH SIDEWALK IMPROVEMENTS
<br /> 1 . This sworn statement is submitted by: � Q f l4 ix1S ` fiun r�
<br /> nn (Name of entitt�v�su�bmitting sworn statement)
<br /> whose business address is : � 3C' U /�v'UC :� C� o f M nuZ
<br /> r f � -I � rnc- � L 3 :r1BS and
<br /> (if applicable) its Federal Employer Identification Number (FEIN) is `1 -
<br /> _7L-f0Fl2
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> r sworn statement — )
<br /> 2 . My name is
<br /> (Please print name of Ind viduaI sig ng)
<br /> and my relationship to the entity named above is (� C" t c70 YI �
<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 /> 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 /> MIN 5 . Based on information and belief, the statement which 1 have marked below is true in
<br /> relation to the entity submitting this sworn statement. [Please indicate which statement
<br /> r applies .]
<br /> Neither the entity submitting this sworn statement, nor any officers , directors ,
<br /> r 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 /> AIN
<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 /> r
<br /> r 0201 -00452 - Disclosure of Relationships
<br /> 00452 - 1
<br /> Rive` Dnve Sidewalk-South-Highland Drive SWt0201 Indian River Drive scum Sidewalk - contractDas10201 •00652 -
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