9-00452 - Disclosure.pdf
PDF 131 KB Posted
- Attached to
- REBID - Floravon Shores Septic to Sewer
- Solicitation number
- 2026027
- Issued by
- Indian River County, Florida
About this file
This is a Disclosure of Relationships form required by Indian River County, Florida for vendors submitting bids on the Floravon Shores Septic to Sewer project. The form serves as a sworn statement to disclose any familial, business, or management relationships between the bidding entity and Indian River County Commissioners or employees. Bidders must declare whether they or any of their officers, directors, executives, partners, shareholders, employees, members, or agents actively involved in management have relationships with county officials as defined in Section 105.06 of the Indian River County Code. The relationships requiring disclosure include immediate family members, in-laws, step-relations, half-siblings, and grandparents or grandchildren. The underlying construction project involves the development of a new gravity sanitary sewer system serving residential areas along 110th Place, 110th Street, and US Highway 1, encompassing approximately 893 linear feet of 8-inch sewer pipe, 5 manholes, 418 linear feet of 8-inch HDPE directional bore sewer, 19 service laterals, and all associated appurtenances.
The disclosure form requires the submitting party to swear under penalty of perjury that all information provided is accurate. Bidders must notify procurement@indianriver.gov if any new affiliate relationships with county officials are identified after form submission. The project requires bidders to submit SURETY2000 electronic bonds in addition to certified or cashier's checks as detailed in Article 8 of the Instructions to Bidders. Prime contractors must execute a Non-Disclosure Agreement no less than 14 days prior to the bid due date to access confidential project plans, with only one email address per prime contractor permitted access under the NDA.
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Text version
Disclosure of Relationships -1
00452-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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