7-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Solicitation number
- 2027003
- 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 or proposals in response to the RFQ for 82nd Avenue Utility Corridor Consulting Services (Project Development Phase). The form mandates that all bidding entities disclose any familial, professional, or financial relationships between firm officers, directors, executives, partners, shareholders, employees, members, or agents active in management and any Indian River County Commissioners or County employees. The disclosure requirements encompass a comprehensive list of relationships including immediate family members, in-laws, step-relations, and half-relations, as well as business affiliates as defined in Section 105.06 of the Indian River County Code.
Bidders must certify under penalty of perjury whether their entity and all active management personnel have no relationships with County officials or employees, or must disclose any such relationships by providing the name of the affiliated party, the name of the County Commissioner or employee, and the nature of the relationship. Any new affiliate relationships identified after form submission must be reported to procurement@indianriver.gov. This disclosure requirement is a standard compliance measure designed to ensure transparency and prevent conflicts of interest in the procurement process for the 82nd Avenue Utility Corridor consulting services project, which involves pre-design planning, coordination, and project development for water and wastewater service expansion.
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Other files
| File | Type | Posted |
|---|---|---|
| 9-Attachment A.pdf | ||
| 11-SOQs Received.docx | DOCX document | |
| 4-Form - Lobbying.pdf | ||
| 2-Form - Scrutinized.pdf | ||
| 8-Sample Professional Services Agreement.docx | DOCX document | |
| 3-Form - Foreign Entity Ownership.pdf | ||
| 1-Form - Debarment.pdf | ||
| 6-Form - Anti-Human Traffic.pdf | ||
| 10-Addendum 1.pdf | ||
| 5-Form - RFP-RFQ Compliance Form.pdf |
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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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