4-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- North County Library Roof Replacement
- Solicitation number
- 2026032
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida, for entities bidding on the North County Library Roof Replacement project. The form serves as a sworn statement to disclose any relationships between the bidding entity and Indian River County Commissioners or County employees. Bidders must declare whether they, their officers, directors, executives, partners, shareholders, employees, members, or agents actively involved in management have any familial or professional relationships with county officials, including spouses, parents, children, siblings, in-laws, step-relations, half-relations, grandparents, or grandchildren. The form requires submission of the firm name, business address, signatory name, and the signatory's relationship to the entity.
Bidders must select either option (a) confirming no relationships exist with county officials or option (b) listing specific relationships by name, title, and relationship type. Submission of the completed form is mandatory, and any new affiliate relationships identified after form submission must be reported to procurement@indianriver.gov. The signatory must attest under penalty of perjury that all information provided is true and accurate. This disclosure requirement is established under Section 105.06 of the Indian River County Code and is designed to identify potential conflicts of interest prior to contract award.
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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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