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r <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 - <br />