3-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- RFQ for Attainable Housing Trust Fund Services
- Solicitation number
- 2026025
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form for Indian River County, Florida, required as part of the RFQ for Attainable Housing Trust Fund Services. The form requires firms submitting proposals to disclose any relationships between the entity and its affiliated officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management with any Indian River County Commissioner or County employee. As defined by Section 105.06 of the Indian River County Code, disclosable relationships include immediate family members, extended family connections, and in-law relationships. Respondents must certify under penalty of perjury whether no such relationships exist or must provide detailed disclosure of any identified relationships, including the names of the affiliated parties, the County Commissioner or employee involved, and the nature of the relationship.
The form stipulates that firms must notify procurement@indianriver.gov immediately should any new affiliate relationships be identified after submission. This disclosure requirement is part of the broader solicitation restrictions prohibiting respondents and their agents from communicating with the Board of Commissioners, Affordable Housing Assistance Committee, County Administrator, or any County staff other than Procurement personnel regarding the solicitation. These communication restrictions remain in effect from RFQ issuance through the Board of County Commissioners' final award authorization meeting, with violations potentially resulting in disqualification.
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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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