7-Form - Disclosure Form.pdf
PDF 130 KB Posted
- Solicitation number
- 2027009
- 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 North County Aquatic Center Commercial Pool Spray Feature Replacement project. The form is a sworn statement in which bidders must disclose whether they or any of their officers, directors, executives, partners, shareholders, employees, members, or agents active in management have relationships with any Indian River County Commissioner or County employee. The disclosure requirements apply to specific family relationships and affiliates as defined in Section 105.06 of the Indian River County Code, including spouses, children, parents, siblings, in-laws, step-relations, half-relations, grandparents, and grandchildren. Bidders must select either option (a) confirming no such relationships exist, or option (b) detailing any relationships that do exist by providing the names of the affiliated parties, the County official or employee involved, and the nature of the relationship.
The form requires the submitting firm to provide its business address and the name and role of the person completing the disclosure. Signatories attest under penalty of perjury that the information provided is true and accurate. Any new affiliate relationships identified after form submission must be reported to procurement@indianriver.gov. This disclosure requirement is designed to identify potential conflicts of interest and ensure transparency in the competitive bidding process for county contracts.
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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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