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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 .
<br /> This sworn statement is submitted with Bid , Proposal or Contract No . 2008027 for the South RO Water
<br /> i Treatment Plant Improvements .
<br /> I . This sworn statement is submitted by : Co "
<br /> (Name of entity submitting sworn statement )
<br /> whose business address is : C, 4( *il Cowa
<br /> �naow� �l 3b �cri and
<br /> (if applicable) its Federal Employer Identification Number (FEIN) is cy- .2-77 -3123 ( If the
<br /> entity has no FEIN , include the Social Security Number of the individual signing this
<br /> sworn statement ) .
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<br /> 2 . My name is �, tiv kA
<br /> (Please print name of individual signing)
<br /> and my relationship to the entity named above is NcsileAi
<br /> 3 . I understand that an " affiliate " as defined in Section 105 . 08 , Indian River County Code , means :
<br /> The term "affiliate " includes those officers, directors, executives, ' partners, shareholders,
<br /> employees, members, and agents who are active in the management of the entity.
<br /> 4 . I understand that the relationship with a County Commissioner or County employee that must be
<br /> disclosed is as follows :
<br /> Father, mother, son, daughter, brother, sister, uncle, aunt, first cousin,
<br /> nephew, niece, husband, wife, father- in - law, mother- in - law, daughter- in -
<br /> law, son - in - law, brother- in- law, sister- in - law, stepfather, stepmother,
<br /> stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
<br /> grandparent or grandchild.
<br /> 5 . Based on information and belief, the statement which I have marked below is true in relation to the
<br /> 1 entity submitting this sworn statement . Please indicate which statement applies .
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<br /> _ Neither the entity submitting this sworn statement, nor any officers , directors , executives ,
<br /> partners , shareholders , employees , members , or agents who are active in management of the
<br /> entity , have any relationships as defined in Section 105 . 08 , Indian River County Code , with any
<br /> 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 in
<br /> management of the entity have the following relationships with a County Commissioner or
<br /> County employee :
<br /> 044572017
<br /> 00452- 1
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