3-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Round Island Shelters Columns Replacement
- Solicitation number
- 2027006
- Issued by
- Indian River County, Wilton Manors City, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida for vendors and contractors bidding on the Round Island Shelters Columns Replacement project in Vero Beach. The form requires firms to disclose any relationships between the entity, its officers, directors, executives, partners, shareholders, employees, members, or agents actively involved in management and any Indian River County Commissioners or County employees. The disclosure must identify specific family relationships as defined in Section 105.06 of the Indian River County Code, including immediate family members, in-laws, step-relations, half-siblings, and grandparents or grandchildren. Submitting firms must indicate whether no such relationships exist or provide detailed information about any identified relationships, including the names of affiliated individuals, the County personnel involved, and the nature of the relationship.
The form requires sworn statements under penalty of perjury and mandates that firms notify the County's procurement department at procurement@indianriver.gov if any new affiliate relationships are identified after submission. This disclosure requirement is a standard compliance mechanism to ensure fair competition and prevent conflicts of interest in the County's procurement process for the structural column replacement project at Round Island Park.
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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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