3-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Annual Bid for 93% Sulfuric Acid
- Solicitation number
- 2027001
- 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 bids on the Annual Bid for 93% Sulfuric Acid contract opportunity. The form serves as a sworn statement in which bidding firms must disclose any relationships between the firm's officers, directors, executives, partners, shareholders, employees, members, or agents active in management and any Indian River County Commissioners or County employees. The form defines "affiliate" relationships broadly to include immediate family members, in-laws, and step-relations as specified under Section 105.06 of the Indian River County Code. Bidders must certify under penalty of perjury whether no such relationships exist or, if relationships do exist, provide detailed information identifying the affiliated individual, 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, along with the name and relationship of the individual completing the statement. Bidders must select either option (a), certifying no relationships exist with County personnel, or option (b), detailing any disclosed relationships in a provided table. The form includes a notification requirement stipulating that any new affiliate relationships identified after submission must be reported to procurement@indianriver.gov. Submission of this disclosure form is a compliance requirement for participation in the Indian River County procurement 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: |
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| b: |
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