4-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Solicitation number
- 2027007
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure Form related to the Sandridge Golf Course Cart Barns Roof Replacement project in Vero Beach, Florida. The form serves as an official disclosure document for entities bidding on or involved with this state and local contract opportunity. The project involves providing all labor, supervision, materials, equipment, and incidentals necessary to remove and replace roof covering on cart barns at Sandridge Golf Course located at 5300 73rd Street, Vero Beach, FL 32967. The disclosure form functions as a standardized document used by the jurisdiction to collect relevant information from bidders and contractors regarding their qualifications, affiliations, and compliance with local and state requirements.
The specific details contained within the form regarding pricing terms, set-asides, incumbent contractor information, funding sources, and other salient contractual terms would be outlined within the document's content sections. Disclosure forms of this nature typically require bidders to provide information about their business structure, ownership, experience, and any potential conflicts of interest to ensure transparency and compliance with procurement regulations.
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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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