10-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Property Appraiser Office Remodel (Rebid)
- Solicitation number
- 2027014
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida, for vendors bidding on the Property Appraiser Office Remodel (Rebid) project. The form serves as a sworn statement to disclose any familial, financial, or business relationships between the bidding entity and Indian River County Commissioners or County employees. Bidders must declare whether they, or any of their officers, directors, executives, partners, shareholders, employees, members, or agents active in management have relationships with County officials as defined in Section 105.06 of the Indian River County Code. The disclosure covers a comprehensive list of relationships including spouses, children, parents, siblings, in-laws, and other extended family members.
Bidders must select either option (a) stating no such relationships exist, or option (b) to list any relationships present, including the name of the affiliate, the County official involved, and the nature of the relationship. The form requires the bidder's firm name, business address, the signatory's name and relationship to the entity, and must be executed under penalty of perjury. If new affiliate relationships are identified after submission, vendors are required to notify procurement@indianriver.gov. This disclosure requirement ensures transparency and helps prevent conflicts of interest in the County's procurement process for the interior renovation project.
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Text version
Disclosure of Relationships -1
DISCLOSURE OF RELATIONSHIPS
1. This sworn statement is submitted by (firm name):
whose business address is: .
2. My name is and my relationship to the entity named above is .
3. I understand that as defined in Section 105.06, Indian River County Code, the term
“affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of the entity.
4. I understand that the relationship with a County Commissioner or County employee that must be disclosed as follows:
Self (current county employee or commissioner), father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, or grandchild.
5. Based on information and belief, the statement, which I have marked below, is true in relation to the entity submitting this sworn statement. [Please select either a. or b.]
a. Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, have any relationships as defined in section 105.06, Indian River County Code, with any County Commissioner or County employee; or,
b. The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents, who are active in management of the entity have the following relationships with a County Commissioner or County employee:
Name of Affiliate of entity Name of County Commissioner or employee Relationship
6. Should a new affiliate relationship be identified after the submittal of this form, I will notify procurement@indianriver.gov.
7. I hereby swear, under penalty of perjury, the information provided on this form is true.
(Signature)
(Date) mailto:procurement@indianriver.gov
| 1 This sworn statement is submitted by firm name: |
| whose business address is: |
| 2 My name is: |
| my relationship to the entity named above is: |
| a: |
| b: |
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