1-CONFLICT OF INTEREST STATEMENT FORM.pdf

1 MB Posted

Attached to
26B-026 Marion County Street Sweeping 2026
Solicitation number
26B-026
Issued by
Marion County, Florida

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This document is a Conflict of Interest Statement form governed by Florida Statute §112.313, designed for potential vendors or contractors with a county government entity (MCBCC). The form requires respondents to disclose any potential conflicts of interest related to county employees, public officers, or advisory board members, including personal relationships, employment connections, or ownership interests that might create a conflict when contracting with the county.

The form is structured in two parts, with Part 1 requiring disclosure of various potential conflict scenarios, such as being a county employee, having a familial relationship with a county official, or having a material interest in the respondent business. Part 2 addresses whether an advisory board member waiver will be requested. The county reserves the right to review and disqualify any vendor with unwaived or non-exempt conflicts under the Florida Ethics Code. Respondents must complete the form by checking applicable boxes, providing names where relevant, and signing to attest to the accuracy of their disclosures.

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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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