3-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Annual Bid to Furnish and Deliver Polymer
- Solicitation number
- 2027002
- 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 county contracts. The form mandates that bidders disclose any familial or business relationships between the bidding entity's officers, directors, executives, partners, shareholders, employees, members, or agents active in management and any Indian River County Commissioner or County employee. The disclosure covers a comprehensive list of relationships including spouses, parents, children, siblings, in-laws, step-relations, half-relations, grandparents, and grandchildren. Bidders must certify under penalty of perjury whether such relationships exist and, if they do, must identify the specific affiliate, the County official or employee involved, and the nature of the relationship.
The form requires that any new affiliate relationships discovered after submission be reported immediately to procurement@indianriver.gov. This disclosure mechanism applies to the Annual Bid to Furnish and Deliver Polymer for Indian River County, which seeks firm fixed prices for polymer delivery on an as-needed basis for the period October 1, 2026, through September 30, 2027. The form serves as a conflict-of-interest safeguard to ensure competitive integrity and compliance with Indian River County Code Section 105.06.
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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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