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<br /> A
<br /> 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 OR OTHER OFFICER AUTHORIZED TO ADMINISTER
<br /> "w OATHS .
<br /> 1 . This sworn statement is submitted by: l� Q hose
<br /> business address is :
<br /> applicable) its Federal Employer Identification Number (FEIN ) is ( Ifnd ( 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 Please
<br /> ( print name of
<br /> individual signing ) and my rela ' nship to the entity named above is
<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 /> .rr stepbrother, stepsister, half brother, half sister, grandparent , or grandchild .
<br /> 5 . Based on information and belief, the statement, which l have marked below , is true
<br /> in relation to the entity submitting this sworn statement . ' [Please indicate which
<br /> statement applies .]
<br /> +r
<br /> Neither the entity submitting this sworn statement , nor an officers directors ,
<br /> ,
<br /> _ executives, partners, shareholders , employees,_ members or agent1. s 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 qr County employee :
<br /> CADocuments and Settingskhrisk\Local SeltingMTemporary Internet RISMOLK626UEANNE EMERGENCY CONTRACT 2004 Am
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