4-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Indian River County West Regional / Glendale Wastewater Treatment Facility Metal Roof Panel Replacement
- Solicitation number
- 2027004
- 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 metal roof panel replacement project at the West Regional/Glendale Wastewater Treatment Facility. The form requires the submitting firm to disclose whether any officers, directors, executives, partners, shareholders, employees, members, or agents active in management have relationships with Indian River County Commissioners or County employees as defined by Section 105.06 of the Indian River County Code. Acceptable relationships requiring disclosure include family relations such as spouses, parents, children, siblings, in-laws, step-relations, half-relations, and grandparents or grandchildren. Bidders must certify under penalty of perjury that the information provided is accurate and must notify the procurement department at procurement@indianriver.gov if any new affiliate relationships are identified after form submission.
The form contains two certification options: option (a) allows bidders to attest that neither the entity nor any of its management personnel have relationships with County officials, while option (b) requires detailed disclosure of any such relationships, including the name of the affiliate, the name of the County Commissioner or employee, and the nature of the relationship. The form serves as a conflict-of-interest screening mechanism to ensure compliance with Indian River County procurement regulations and maintain transparency in the competitive bidding process for the wastewater treatment facility project.
View the file
Other files
Show all 16
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .