6-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Annual Bid for Liquid Carbon Dioxide
- Solicitation number
- 2026023
- 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 on the Annual Bid for Liquid Carbon Dioxide contract opportunity. The form serves as a sworn statement to disclose any relationships between the bidding entity (including its officers, directors, executives, partners, shareholders, employees, members, and agents active in management) and Indian River County Commissioners or County employees. The disclosure requirements cover a comprehensive list of family and business relationships including spouses, parents, children, siblings, in-laws, step-relations, and half-relations, as defined in Section 105.06 of the Indian River County Code.
Bidders must certify under penalty of perjury that either no such relationships exist with any County Commissioner or employee, or fully disclose any identified relationships by providing the name of the affiliate, the name of the County Commissioner or employee, and the nature of the relationship. The form requires a signature and date from the submitting party and mandates notification to procurement@indianriver.gov if any new affiliate relationships are identified after form submission. This disclosure requirement is a standard compliance measure designed to identify and prevent potential conflicts of interest in the procurement process.
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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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