Familial Disclosure Statement.docx
DOCX document 14 KB Posted
- Attached to
- Request High School Auditorium A/V Upgrades
- Solicitation number
- RFP LKWD 210000001915 3
- Issued by
- Baraga County, Michigan
About this file
This is a Familial Disclosure Statement required by Lakewood Public Schools in Michigan pursuant to MCL 380.1267. The statement must accompany all bids and proposals submitted in response to the district's Request for Proposal. Bids and proposals submitted without the completed disclosure statement will not be accepted. The form requires vendors and contractors to disclose any familial relationships that exist between the owner or any employee of the vendor/contractor and members of the Lakewood Public Schools Board of Education or the Superintendent. The Board members identified are Frank Pytlowany, Jamie Brodbeck-Krenz, Lynn MacKenzie, Steve St. Laurent, Melissa McClelland, Kerry Possehn, and Darin Weller, with Steven Skalka serving as Superintendent.
Bidders must certify under oath, with notarization, that all disclosure statements provided are true and accurate. The form provides space to list up to five familial relationships with space for the owner/employee name, the related board member or superintendent, and the nature of the relationship. If no familial relationships exist, bidders must indicate this on the form. Additional pages may be attached if necessary to disclose all relationships. The completed statement must be signed by the bidder or authorized representative and notarized by a Michigan notary public before submission.
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Other files
| File | Type | Posted |
|---|---|---|
| Iran Economic Sanctions Document - LHS Auditorium.docx | DOCX document | |
| AUDITORIUM AV UPGRADE.pdf |
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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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