6-Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Courthouse Generator
- Solicitation number
- 2026018
- 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 Courthouse Generator project. The form mandates that all bidders submit a sworn statement disclosing any relationships between the entity and its affiliates—defined as officers, directors, executives, partners, shareholders, employees, members, and agents active in management—and any Indian River County Commissioners or County employees. Bidders must disclose relationships including immediate family members, extended family relations, and in-laws as specified in Section 105.06 of the Indian River County Code.
The disclosure requires bidders to indicate whether no relationships exist with County officials or employees, or to provide detailed information about any such relationships, including the names of affected affiliates and the County personnel involved. Bidders must submit the completed form under penalty of perjury and commit to notifying the procurement office at procurement@indianriver.gov if any new affiliate relationships are identified after form submission. This disclosure mechanism ensures transparency and helps prevent conflicts of interest in the County's competitive bidding process for the generator replacement project.
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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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