1-Conflict Of Interest Statement.pdf
PDF 1 MB Posted
- Attached to
- 26B-104 Asphalt Pavement Restoration Services
- Solicitation number
- 26-104
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement form required by Florida Statute 112.313 for vendors responding to Marion County Utilities' Request for Proposal for Asphalt Pavement Restoration Services (Contract 26B-104). The form is designed to identify any prohibited relationships between the respondent and County employees, public officers, or advisory board members that could create conflicts of interest under Florida's ethics code.
The statement requires respondents to disclose whether they are County employees or advisory board members, whether they are related to such individuals, whether County employees or their family members have material interests in the respondent company, whether the respondent employs or contracts with County personnel, or whether the respondent's principal or agent is a former Marion County Board of County Commissioners employee with less than one year of inactive service. Respondents must also indicate whether they intend to request an advisory board member waiver under Florida Statute 112.313(12). The County reserves the right to review any relationships that may violate the Florida Ethics Code and will disqualify vendors whose conflicts are not waived or determined to be exempt. The form requires certification through signature and identification of the company and authorized representative completing the disclosure.
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Other files
| File | Type | Posted |
|---|---|---|
| 2-ITB - GENERAL TERMS AND CONDITIONS.pdf | ||
| 5-01 26B-104 Bid Table.pdf | ||
| 3-Vendor Information Form.pdf | ||
| 4-02 26B-104 Scope of Work.pdf |
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Text version
CONFLICT OF INTEREST STATEMENT
Florida Statute §112.313 places limitations on public officers (including advisory board members) and employees' ability to contract with the County either directly or indirectly. Therefore, please indicate if the following applies:
PART 1.
I am an employee, public officer, or an advisory board member of the County (LIST).
NAME:
I am the spouse or child of an employee, public officer or advisory board member of the County.
NAME:
An employee, public officer, or advisory board member of the County, or their spouse or child, is an officer, partner, director, or proprietor of Respondent or has a material interest in Respondent. "Material interest" means direct or indirect ownership of more than five percent (5%) of the total assets or capital stock of any business entity. For the purposes of FS §112.313, indirect ownership does not include ownership by a spouse or minor child.
NAME:
Respondent employs or contracts with an employee, public officer, or advisory board member of the County.
NAME:
Principal or Agent is former employee of MCBCC with less than one (1) year of inactive service.
NAME:
NONE OF THE ABOVE
PART 2.
Are you going to request an advisory board member waiver?
I will request an advisory board member waiver under FS §112.313(12)
I will NOT request an advisory board member waiver under FS §112.313(12)
N/A
The County shall review any relationship which may be prohibited under the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or exempt.
COMPANY:
PRINTED NAME:
SIGNATURE:
| NAME: |
| NAME_2: |
| NAME_3: |
| NAME_4: |
| NAME_5: |
| Check Box: Off |
| Check Box3: Off |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
| Check Box9: Off |
| PRINTED NAME: |
| COMPANY: |
| Check Box1: Off |
| Check Box4: Off |
| Signature_es_:signature: |
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