3-00452 - Disclosure.pdf
PDF 136 KB Posted
- Solicitation number
- 2025067
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form (00452) required by Indian River County for entities submitting bids or proposals to the county. The form requires disclosure of any familial or personal relationships between the submitting entity's affiliates (officers, directors, executives, partners, shareholders, employees, members, and agents active in management) and any County Commissioner or County employee. The relationships that must be disclosed include immediate family members, in-laws, step-relatives, half-relatives, and grandparents/grandchildren as defined in Section 105.08 of the Indian River County Code.
The form provides two options for disclosure: either certifying that no covered relationships exist, or identifying specific relationships by listing the name of the entity's affiliate, the name of the County Commissioner or employee, and the nature of their relationship. The document must be completed under penalty of perjury with a signature and date, ensuring transparency in the county's procurement process to avoid potential conflicts of interest or appearances of impropriety in contract awards.
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Text version
Disclosure of Relationships – 00452-1
00452-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 105.08, 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, 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 105.08, 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. I hereby swear, under penalty of perjury, the information provided on this form is true.
(Signature)
(Date)
| 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: |
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