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4 :
<br /> 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 .
<br /> This sworn statement is submitted with Bid , Proposal or Contract No . 2009037 for the
<br /> ROADWAY IMPROVEMENTS TO 16" STREET FROM 74th AVENUE TO 66th AVENUE AND
<br /> 66th AVENUE FROM 16th STREET TO S . R. 60, C . P . 9920198110-A, 0545 .
<br /> 1 . This sworn statement is submitted by : :ar - w - C �X eu #i c . L L c.
<br /> ( Name of entity submitting sworn statement)
<br /> whose business address is: '73 y - -+ ft
<br /> Waif Q" � n^ 43 � � ✓i , GL • � 3 >7 ! 3 and
<br /> (if applicable) its Federal Employer Identification Number ( FEIN) is 2 0 I R 2-
<br /> S k 7
<br /> 2. My name is 5e, ),- d r-'t • /� oksSF} ✓ I
<br /> (Please print name of individual signing )
<br /> and my relationship to the entity named above is v C C- c- R ,5
<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 /> S shareholders, employees, members, and agents who are active in the management
<br /> 1 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, 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 /> F:\Ene neerin,\Capital Projects\9920-16th St, 74th Ave to 66th Ave\9920 Contract Documents & Specs\00452 Disclosure of Aelationships.doc
<br /> 00452- 1
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