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SWORN STATEMENT UNDER SECTION 105 . 08, INDIAN RIFER COUNTY CODE. ON
<br /> ,. DISCLOSURE OF RELATIONSHIPS
<br /> THIS FORM MUST BE SIGNED IN THE PRESENCI OF A NOTARY PLBLIC OR OTHER
<br /> r OFFICER AUTHORIZED TO ADMINISTER OATHS .
<br /> 1 . This sworn statement is submitted with Bid, Proposal or Contract No . 200 ' 033
<br /> r for Gifford Park Secunty House
<br /> 2 . This swomstatementissubmittedby: Passage Island Homesf Inc
<br /> r
<br /> (Name of entity submitting Statement)
<br /> _ whose busness address is :
<br /> 1910 82nd Avenue # 205 , Vero Beach , FL 32966 and (if
<br /> r applicable) its Federal EmployerldentifoationNumbei- (FEL\) is 59 - 3456562 (if the entity has
<br /> no FEIN, include the Social Security 'Number of the individual signing this sworn statement
<br /> .. J
<br /> 3 . N2ynameis Brian F . Adams
<br /> r (Please print name of individual signing)
<br /> and my relationship to the entity named above is Pres i den t
<br /> 4. 1 understand that an "affiliate" as defined in Secticn 105 . 08 , Indian River County Code, means :
<br /> The term "affiliate" includes those officers, Lectors, executives, partners, shareholders,
<br /> employees, members, and agents who are active in the management of the entity.
<br /> 5 . I understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed as follows :
<br /> r
<br /> Father, mother, son, daughter, brother, sister, untie, aunt; first cousin, nephew, niece, husband,
<br /> wife, father-in-law, mother-in-law, daughter-in-lacy, son-in-law, brother-in-law, sister-in-law;
<br /> stepfather, stepmother, stepson, stepdaughter, stepbrother; stepsister, half brother, half sister,
<br /> grandparent, or grandchild.
<br /> r 6 . Based on information and belief the statement, which I have marked below, is true in relation to
<br /> the entity submitting this sworn statement. [Please indicate which statement applies. ]
<br /> r xx Neither the entity submitting this sworn statement, nor any officer, directors,
<br /> executives, parmers, shareholders, employees, member, or agents who are active in
<br /> r management of the entity; have any relationships as defined in section 105 . 08 , Indian River
<br /> County Code, -Mth any County Commissioner or County employee.
<br /> The entity submitting this sworn statement, or one or more of the officers, directors,
<br /> executives, Partner, shareholders, employees, members, or agents, who are active in
<br /> management of the entity have the following relationships with a County Commissioner or
<br /> .. County employee :
<br /> Pone 2d nFACI
<br />
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