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SECTION 00452 - Sworn Statement under Sect. 106. 08 Indian River County Code on
<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 , 0 21 -7 for
<br /> Powerline Road from C . R . 510 North to the Sebastian City Limits
<br /> 1 . This sworn statement is submitted by : _ Z. W . CA160 tN . Lw1wY1 1,...L.C.
<br /> (Name of entity submitting sworn statement)
<br /> whose business address is : I C, L.t ) �� oc ICLce
<br /> WsrzS ?63kyr Q P�Nw%% a t= L 1A LA M and
<br /> (if applicable) its Federal Employer Identification Number (FEIN ) is
<br /> (If the entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement _ ) .
<br /> 2 . My name is
<br /> (Please print name o i dividual signing)
<br /> and my relationship to the entity named above is icp P re N de YX t
<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 /> 4 . 1 understand that the relationship with a County Commissioner or County employee that
<br /> must be disclosed is as follows :
<br /> M Father, mother, son, daughter, brother, sister, uncle, aunt, first
<br /> cousin, nephew, niece, husband, wife, father4n-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 /> The entity submitting this sworn statement, or one or more of the officers , directors ,
<br /> executives , partners , shareholders , employees , members , or agents who are active
<br /> in management of the entity have the following relationships with a County
<br /> Commissioner or County employee :
<br /> I 00452 - Disclosure of Relationships
<br /> 00452 - 1
<br /> FAEnginsering%Capital Projects\0217-Powerline RoacASid DouxnerdsW0452 - Disclosure of Relationshps.doc
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