4-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Sandridge Golf Club Bulkhead Replacement
- Solicitation number
- 2026022
- 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 or proposals on government contracts. The form requires the submitting firm to disclose any relationships between the entity's officers, directors, executives, partners, shareholders, employees, members, or agents active in management and any Indian River County Commissioners or County employees. The disclosure applies to a specific family and professional relationship categories as defined in Section 105.06 of the Indian River County Code, including immediate family members, in-laws, and step-relations. Bidders must certify under penalty of perjury that the information provided is accurate, and any newly identified affiliate relationships must be reported to procurement@indianriver.gov after form submission.
The form serves as a compliance and conflict-of-interest prevention mechanism for the Sandridge Golf Club Bulkhead Replacement project in Indian River County, Florida, which involves labor and material provision for bulkhead replacement according to specifications developed by Kastner Engineering, LLC. The disclosure requirement ensures transparency and integrity in the procurement process by identifying potential conflicts of interest that could compromise fair competition or proper contract administration. Firms must complete all required fields with signatory information and dates before submission.
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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: |
| Textfield: |
| Textfield-0: |
| Textfield-1: |
| Textfield-2: |
| Textfield-3: |
| Textfield-4: |
| Textfield-5: |
| Textfield-6: |
| Textfield-7: |
| Date: |
File details come from the government source that posted it. Updated .