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<br /> SECTION 00452 - Sworn Statement under Sect. 105 . 0 8 Indian River County Code on
<br /> .. Disclosure of Relation p
<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 . 0016 & 0236 for 41 st
<br /> Street Roadway Improvements . 11 `
<br /> +• 1 . . This sworn statement is submitted by : 1�+�r+w�.r
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is : Po f3OX 'cb 3 and
<br /> r` (if applicable) its Federal Employer Identification Number ( FEIN ) Is 5°1 ' Z02 Z
<br /> ( If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement
<br /> 2 . My name is Rod,, s Sr�h+ dL eor'
<br /> (Please punt name inw dual �ni :
<br /> .r and my relationship to the entity named above is
<br /> 3 . I 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 /> 4^
<br /> applies .]
<br /> - '.
<br /> .. 1 ..
<br /> E;
<br /> Neither the entity submitting this sworn statement, nor any officers , directors ,
<br /> M : executives , partners , shareholders , employees , members , or agents who are active in
<br /> .,
<br /> nships as defined in Section 105 . 08 , Indian
<br /> management of the entity , have any relatio
<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 ,
<br /> or agents who are active
<br /> in management of the entity have the following relationships with a County
<br /> Commissioner or County employee :
<br /> v
<br /> 0016-00452 - Disclosure of Relationships
<br /> 00452 - 1
<br /> . n,n.: M9LatN Cl rnrr.�'r nrr��001s 60452- Olseieureaf. fiolati^^ �;^� r .Rev. 05101
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