|
SECTION 00452 — SWORN STATEMENT UNDER SECTION 105 . 08 , INDIAN RIVER
<br /> COUNTY CODE . ON 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 swom statement is submitted with Bid , Proposal or Contract No. 9219 for EAST GIFFORD
<br /> STORMWATER IMPROVEMENTS . f , -
<br /> 1 . This swom statement is submitted by: b , Gkef w f:� ( OF , Aa- 1 Inc,
<br /> � �� � � � me of entity, submitting sworn statement)
<br /> Whose business address is: '(�(Na� �i �. t,V St L 3 `f 99 7
<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 )•
<br /> b CLA
<br /> 2. My name is �'- ar r `'�
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is wreni At V)
<br /> 1 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, father4n4aw, mother-in-
<br /> law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, step-
<br /> father, stepmother, stepson, stepdaughter, stepbrother, stepsister,
<br /> 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 swom statement. [Please indicate which statement
<br /> ap /Neither
<br /> .]
<br /> the entity submitting this swom 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 /> jCommissioner or County employee:
<br /> 00452 - Swam Statement under Sed. 105.08 Indian River County Code on Disdosum-of Relationships
<br /> 00452 - 1 61
<br /> Fiftbtk worksV(aMA lStomnwster PraiectsOffard EasllCoratrudkn ContradlConstrudkn ContradVM52 . swam statement urWar sad. 105.09 b'dw River couvty Cods
<br /> on D150mire of PAMonshlps doc Rev. 05101-
<br />
|