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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 OATHS . os 3
<br /> This sworn statement is submitted with Bid , Proposal or Contract Nos./ for
<br /> the Paving and Drainage Improvements to 17th Lane SW from 27th Avenue to East
<br /> approx . 90020 Avenue from 21 " Street SW to 17t Lane SW and 17th Lane from
<br /> Falcon Trace Project Entrance to 20t Avenue .
<br /> �,�,,, L L
<br /> 1 . This sworn statement is submitted by : � ' `w& A '
<br /> I ( Name of entity submitting sworn statement)
<br /> whose business address is : 7 act ` 14/ens Po oo + P I
<br /> W P• 6, iG L 3 ti 3 and
<br /> (if applicable ) its Federal Employer Identification Number ( FEIN ) is 2 c ! 9 2 14 7 9
<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
<br />- Disclosure
<br /> s aointinnshios REV 04-07.doc
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