Familial Disclosure Statement.docx
DOCX document 14 KB Posted
- Solicitation number
- RFP LKWD 210000001914 3
- Issued by
- Baraga County, Michigan
About this file
This is a Familial Disclosure Statement required by Lakewood Public Schools for all bids and proposals submitted in response to their Request for Proposal process. Pursuant to Michigan Compiled Law 380.1267, vendors and contractors must submit a sworn and notarized statement disclosing any familial relationships between the owner or employees of the vendor/contractor and members of the Lakewood Public Schools Board of Education or the Superintendent. The Board members identified in the disclosure are Frank Pytlowany, Jamie Brodbeck-Krenz, Lynn MacKenzie, Steve St. Laurent, Melissa McClelland, Kerry Possehn, and Darin Weller, with Steven Skalka serving as Superintendent. Bids and proposals submitted without this completed and notarized disclosure statement will not be accepted.
The disclosure statement requires bidder representatives to either list any familial relationships that exist with the identified board members or superintendent, or attest that no such relationships exist. The statement must be signed by the bidder or authorized representative, include printed name and title, and be acknowledged before a notary public with the notary's signature, seal, and commission expiration date. Additional pages should be attached if necessary to disclose all familial relationships. This document serves as a compliance and transparency measure to ensure vendor impartiality in the procurement process.
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Text version
Lakewood Public Schools Request for Proposal
DISCLOSURE STATEMENT – FAMILIAL RELATIONSHIP - LAKEWOOD PUBLIC SCHOOLS
Pursuant to MCL 380.1267, a sworn and notarized statement disclosing any familial relationship that exists between the owner and any employee of the vendor/contractor and any member of the Lakewood Public Schools Board of Education or the Lakewood Public Schools Superintendent must be accompanied with the bid/proposal.
Bids and Proposals without this disclosure statement will not be accepted.
The members of the Lakewood Public Schools Board of Education are: Frank Pytlowany, Jamie Brodbeck-Krenz, Lynn MacKenzie, Steve St. Laurent, Melissa McClelland, Kerry Possehn, and Darin Weller. The Lakewood Public Schools Superintendent is Steven Skalka.
□ The following are the familial relationship(s):
Owner/Employee Name Related to: Relationship_________
1. _______________________ ________________________ ___________________________
2. _______________________ ________________________ ___________________________
3. _______________________ ________________________ ___________________________
4. _______________________ ________________________ ___________________________
5. _______________________ ________________________ ___________________________ Attach additional pages if necessary to disclose all familial relationships.
□ There are no familial relationships that exist between the owner and any employee of the vendor/contractor and any member of the Lakewood Public Schools Board of Education or the Lakewood Public Schools Superintendent.
The undersigned, the owner or authorized representative of bidder (insert name) _________________________ does hereby represent and warrant that the disclosure statements herein contained are true.
Signature of Bidder Representative
Print Name
Title
STATE OF MICHIGAN )
) ss
COUNTY OF ______________)
This instrument was acknowledged before me on the _____ day of _________________, _______, by ______________________________________________.
, Notary Public _________________County, Michigan My commission expires: ____/____/____ Acting in the County of: _____________
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