4-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Emergency Operations Warehouse Addition
- Solicitation number
- 2026009
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County for entities submitting bids or proposals. The form mandates that bidding firms disclose any familial or business relationships between the firm's officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management with any Indian River County Commissioners or County employees. Specifically, disclosable relationships include immediate family members (spouse, children, parents), extended family (siblings, aunts, uncles, cousins, nephews, nieces), in-laws, step-relations, half-relations, and grandparents or grandchildren. Bidders must certify under penalty of perjury whether such relationships exist and, if they do, must identify the affiliated individual, the County official or employee involved, and the nature of the relationship. The form requires submission of a sworn statement with the bidder's firm name, business address, and the signatory's name and relationship to the entity.
Bidders are required to notify the Indian River County Procurement Division at procurement@indianriver.gov if any new affiliate relationships are identified after form submission. This disclosure requirement is mandated under Section 105.06 of the Indian River County Code and serves as a conflict-of-interest mitigation measure to ensure procurement integrity. The form applies to the Emergency Operations Warehouse Addition project for Indian River County, which involves construction of a single-story pre-manufactured steel structure with complete MEP services, a covered breezeway connector, and associated site work. All bidders must complete and submit this disclosure form as a condition of bid eligibility.
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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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