Attachment C Familial Statement.pdf

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Attached to
FY2025 MISEN Data Center Presence RFP
Solicitation number
RFP-GIS-250000001042-1
Issued by
Genesee County, Michigan

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This is a Familial Relationship Disclosure Statement form required under Public Act 232 of 2004 for the Genesee Intermediate School District's Erwin L. Davis Education Center located in Flint, Michigan. The form requires all bidders to provide a sworn and notarized statement disclosing any familial or business relationships between the bidder, their employees, and any member of the Genesee Intermediate School District Board of Education, Superintendent, or other district officials. Bids submitted without this sworn and notarized statement will not be accepted.

The document requires bidders to provide their company information including name, address, and contact number, followed by a statement section where they must disclose any business or familial relationships. The form must be signed by a person authorized to bind the contractor/vendor/respondent and must be notarized with the notary's seal, signature, commission expiration date, and county of operation clearly indicated.

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Other files

File Type Posted
Attachment E School Safety Affidavit.pdf PDF
MiSEN FY25 Data Center Presence ATTACHMENT A - Specifications & Additional Terms.pdf PDF
MiSEN FY25 Data Center Presence RFP Instruction to Bidders.pdf PDF
Attachment D Iran Economic Sanctions Act Certification.pdf PDF
Attachment B- Data Center Presence - MISEN_Genesee Intermediate School District Bid Form.xlsx XLSX spreadsheet

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Attachment C

GENESEE INTERMEDIATE SCHOOL DISTRICT

ERWIN L. DAVIS EDUCATION CENTER

2413 WEST MAPLE AVENUE

FLINT, MI 48507-3493

PUBLIC ACT 232 OF 2004

FAMILIAL RELATIONSHIP DISCLOSURE STATEMENT

All bids must be accompanied by a sworn and notarized statement disclosing any familial, or other business relationship existing between the bidder (respondent to this Bid) and all employees of the bidder and any member of the Genesee Intermediate School District Board of Education, the Superintendent of the District and/or any other official of the District. Any bids that do not include this sworn and notarized statement shall not be accepted.

Owner Name & Address:

Genesee Intermediate School District 2413 West Maple Avenue

Flint, MI 48507-3493

Contractor/Vendor/Respondent Information:

Name: ______________________________________________________________________

Address: ____________________________________________________________________

)Contact Number: (

Statement of Business or Familial Relationship:

Person Authorized to Bind the Contractor/Vendor/Respondent:

Print Name Title

Signature Date

Seal:

County, This instrument was acknowledged before me, a Notary Public, in and for ___________________________

., 20day of on this ______________________ _________ _______________________ _________ State

Notary Public Signature Date

My Commission Expires: _______________________

Acting in the County of: ________________________

Name:
Address:
Statement of Business or Familial Relationship 1:
Statement of Business or Familial Relationship 2:
Statement of Business or Familial Relationship 3:
Print Name:
Title:
Area Code:
Phone Number:
City State Zip Code:
State:
My Commission Expires:
Acting in the County of:
Date:
county name:
Day:
Month:
Date of signature:
Year:

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