3-Disclosure.pdf
PDF 128 KB Posted
- Solicitation number
- 2026015
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida for vendors and contractors submitting bids on the Operations of the Biosolids Dewatering Facility, Sludge Dewatering, and Hauling contract opportunity. The form mandates that submitting entities disclose any familial or business relationships between the firm's officers, directors, executives, partners, shareholders, employees, members, or agents active in management and any Indian River County Commissioner or County employee. Relationships requiring disclosure include immediate family members, in-laws, step-relations, half-siblings, and grandparents or grandchildren as defined in Section 105.06 of the Indian River County Code. Bidders must certify under penalty of perjury whether such relationships exist and, if they do, provide detailed information identifying the affiliated party, the County official or employee involved, and the nature of the relationship.
The form requires the submitting firm to provide its name and business address, the name and title of the person completing the disclosure, and a sworn statement affirming the accuracy of the information provided. Entities must select either option (a) confirming no relationships exist with County officials or employees, or option (b) detailing any such relationships in a designated table. The form also requires vendors to notify the County's Purchasing Department at purchasing@indianriver.gov should any new affiliate relationships be identified after submission. Failure to accurately complete and sign this disclosure may result in bid disqualification or other contract penalties.
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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 purchasing@indianriver.gov.
7. I hereby swear, under penalty of perjury, the information provided on this form is true.
(Signature)
(Date) mailto:purchasing@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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