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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 /> This sworn statement is submitted with Bid , Proposal or Contract No. 9705C for
<br /> -Oslo Road (CR 606 ) Phase I Roadway Widenina
<br /> 1 . This sworn statement is submitted by: n OD ,L,+ rp Tf C.
<br /> r� oj (Name of en ' submiitlng sworn statement
<br /> whose business address is : f' , ti 3311 11A .a 10. 45-(o
<br /> and
<br /> (if applicable) its Federal Employer Identification Number (FEIN ) is
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement nl ) .
<br /> 2. My name is l . , t ITS
<br /> (Please print name of individual spng) ,y
<br /> and my relationship to the entity named above is V il t_M '�
<br /> 3. 1 understand that an "affiliate" as defined in Section 105. 08 , Indian River County Code,
<br /> means:
<br /> The term "affiliate a 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 /> 00452 - Disclosure of Relationships
<br /> 00452 - 1
<br /> FANNic WorklAGapital ProjeclstOslo Road Oslo Widening, Old Dixie to 27th Av CONTRAGT DOCUMENR00452 - Disclosure of Relationshim.cm Rea. 05101
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