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SWORN STATEMENT UNDER SECTION 105 . 08 ,
<br /> INDIAN RIVER 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 /> 1 . This sworn statement is submitted by : Coastal Services of Florida , LLC , whose
<br /> business address is : 3175 Willfee Road , Ft . Pierce , Florida 34982 and ( if
<br /> applicable ) its Federal Employer Identification Number ( FEIN ) is L6 -7Yf ' ?' 7 y3 ( If the
<br /> entity has no FEIN , include the Social Security Number of the individual signing this sworn
<br /> statement )
<br /> 2 . My name is Z ( Please print name of
<br /> individual signing ) and my r nship to the entity named above is �Ve St,
<br /> 3 . 1 understand that an "affiliate " as defined in Section 105 . 08 , Indian River County
<br /> Code , means : The term "affiliate " includes those officers , directors , executives ,
<br /> partners , shareholders , employees , members , and agents who are active in the
<br /> management of the entity .
<br /> 4 . 1 understand that the relationship with a County Commissioner or County employee
<br /> that must be disclosed as follows :
<br /> Father, mother, son , daughter, brother, sister , uncle , aunt , first cousin , nephew ,
<br /> niece , husband , wife , father- in - law , mother- in - law , daughter- in - law , son - in - law ,
<br /> brother- in - law , sister- in - law , stepfather, stepmother , stepson , stepdaughter,
<br /> stepbrother, stepsister, half brother, half sister, grandparent , or grandchild .
<br /> 5 . Based on information and belief, the statement , which I have marked below , is true
<br /> in relation to the entity submitting this sworn statement . [ Please indicate which
<br /> state pplies . ]
<br /> 7=Neither the entity submitting this sworn statement , nor any officers , directors ,
<br /> executives , partners , shareholders , employees , members , or agents who are active
<br /> in management of the entity , have any relationships as defined in section 105 . 08 ,
<br /> Indian River County Code , with any County Commissioner or County employee .
<br /> The entity submitting this sworn statement , or one or more of the officers ,
<br /> directors , executives , partners , shareholders , employees , members , or agents , who
<br /> are active in management of the entity have the following relationships with a
<br /> County Commissioner or County employee :
<br /> F :\Public Works\Capital Projects\Hurricane Debris Removal\emergency contract CoastaIMULCH . doc 1
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