4-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- RFP for Disaster Debris Management
- Solicitation number
- 2026011
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida, for vendors submitting bids or proposals in response to the RFP for Disaster Debris Management. The form is a sworn statement that obligates the submitting firm to disclose any relationships between the entity, its officers, directors, executives, partners, shareholders, employees, members, or agents active in management and any Indian River County Commissioner or County employee. As defined in Section 105.06 of the Indian River County Code, disclosable relationships include immediate family members (spouse, parents, children, siblings), extended family members (grandparents, grandchildren, aunts, uncles, cousins, nephews, nieces), and in-laws or step-relations of County officials or employees. The form requires the firm to affirm either that no such relationships exist or to identify and provide details regarding any relationships that do exist, including the name of the affiliated person, the name of the County official or employee, and the nature of the relationship.
Vendors must complete all required fields with their firm name, business address, the name and role of the person submitting the form, and either statement (a) confirming no conflicts or statement (b) disclosing specific relationships. The form is submitted under penalty of perjury, and vendors are obligated to notify the Indian River County Procurement Department at procurement@indianriver.gov immediately if any new affiliate relationships are identified after submission. This disclosure requirement is a standard procurement compliance measure designed to prevent conflicts of interest and ensure fair and transparent contracting processes.
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| 7-Form - Lobbying.pdf | ||
| 6-Form - RFP-RFQ Compliance Form.pdf | ||
| 2-Form - Foreign Entity Ownership.pdf | ||
| 10-2026011 RFP for Disaster Debris Management.pdf | ||
| 3-Form - Scrutinized.pdf | ||
| 1-Form - Anti-Human Traffic.pdf | ||
| 8-Proposal Pricing Forms.xlsx | XLSX spreadsheet | |
| 9-2026011 Disaster Debris Management Sample Agreement.docx | DOCX document | |
| 5-Form - Debarment.pdf |
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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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