2-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- MPO General Planning Consultant State and local contract opportunity
- Solicitation number
- 2027005
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida for entities bidding on the MPO General Planning Consultant contract. The form serves as a sworn statement wherein bidders must disclose any relationships between the firm and its active management personnel (officers, directors, executives, partners, shareholders, employees, members, and agents) and Indian River County Commissioners or County employees. The disclosure requirements encompass immediate and extended family relationships, including spouses, in-laws, step-relations, and first cousins.
Bidders must certify under penalty of perjury that either no such relationships exist or provide detailed information identifying any affiliates with relationships to County officials, including the name of the affiliated individual, the name of the County Commissioner or employee, and the nature of the relationship. Bidders are obligated to notify the County procurement department at procurement@indianriver.gov should any new affiliate relationships be identified after form submission. The form requires the firm name, business address, signatory name, signatory title, and signature with date to complete the disclosure requirement.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 8-RFQ 2027005 for MPO General Consulting Services.pdf | ||
| 7-Form - Foreign Entity Ownership.pdf | ||
| 6-Form - RFP-RFQ Compliance Form.pdf | ||
| 5-Form - Debarment.pdf | ||
| 3-Form - Scrutinized.pdf | ||
| 4-Form - Anti-Human Traffic.pdf | ||
| 9-Professional Services Agreement.docx | DOCX document | |
| 10-Exhibit 2 - G3R67 FDOT MPO Agreement.pdf | ||
| 1-Form - Lobbying.pdf |
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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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