|
Exhibit B . 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 that certain Agreement for Donation of Surplus County.
<br /> Owned Lands .
<br /> 1 . This sworn statement is submitted by : 1A10o4.v y
<br /> ✓t � ggiT4T LoJ( fr' u •�r�9Ni ; y
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is : 4956 t3 n/• us /y y , V 440, O S 4'4
<br /> and
<br /> (if applicable) its Federal Employer Identification Number ( FEIN ) is (0 5
<br /> 2 . My name is ' ¢NDdes 4 R • 46 o w `- £ 'c
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is /'R 4C S io4t •N T /G 4E a
<br /> 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, brother4n4aw, 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 /> X 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 />
|