3-Disclosure Form.pdf
PDF 130 KB Posted
- Solicitation number
- 2026016
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships Form required by Indian River County, Florida, for entities submitting proposals or bids on county contracts. The form mandates that proposers disclose any familial, business, or management relationships between the submitting entity's officers, directors, executives, partners, shareholders, employees, members, or agents and any Indian River County Commissioners or County employees. The disclosure requirement applies to relationships defined in Section 105.06 of the Indian River County Code, including immediate family members (spouse, children, parents, siblings), extended family (grandparents, grandchildren, aunts, uncles, cousins, nieces, nephews), and in-laws or step-relations. Proposers must indicate whether no such relationships exist or must provide detailed information listing any affiliated individuals and their specific relationships to county officials or employees. The form requires a sworn statement under penalty of perjury and mandates notification to the procurement department at procurement@indianriver.gov if any new affiliate relationships are identified after form submission.
The disclosure form applies to Indian River County's procurement for a Utilities Computerized Maintenance Management System (CMMS) and Implementation Services. Proposers must submit a single, coordinated solution with either a prime contractor managing both the software provider and implementation partner or with the software provider serving as the implementation servicer. The form serves as a compliance mechanism to ensure ethical procurement practices and prevent conflicts of interest in the county's vendor selection process.
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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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