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SECTION 00452
<br />DISCLOSURE OF RELATIONSHIPS
<br />THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
<br />OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS8
<br />the
<br />aD1
<br />0270), °aA0
<br />This sworn statement is submitted with Bid, Proposal or Contract No's./ for
<br />,Am. Ana Ilrnin!nnc ImnrnvcmanfQ fn 17th I ane SW from 27th Avenue to East
<br />in
<br />n
<br />ne
<br />Falcon Trace Project Entrance to 20"' Avenue.
<br />1. This sworn statement is submitted by: 7Zy'
<br />I (Name of entity submitting sworn statement)
<br />whose business address is: 7 act ` 14/es+ Po oo + P
<br />W P• 6. I✓ L 334 13 and
<br />(if applicable) its Federal Employer Identification Number (FEIN) is 2 c ! 9 2 14 7 cl
<br />2. My name is
<br />(Please print name of individual signing.)
<br />and my relationship to the entity named above is V i L c. Dir. s t 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 />I. 4. 1 understand that the relationship with a County Commissioner or County employee
<br />that 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, brother-in-law, 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 />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 />00452 - Disclosure of Relationships REV 04-07
<br />00452-1
<br />F:\Engineering\Capital Project5\0803 17th Lane SW Roadway Improvements from 27th Ave to approx. 900 LF east of 27th Ave\0803 Contract Documents\00452 - Disclosure
<br />s aointinnshios REV 04-07.doc
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