1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Attached to
- 26Q-073 Tourism Photography and Video
- Solicitation number
- 26-073
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for vendors and respondents seeking to contract with Marion County. The form is designed to identify any potential conflicts of interest involving County employees, public officers, advisory board members, and their immediate family members. Respondents must disclose if they are County employees or officers, if they are related to County personnel, if County officials have material interests (defined as ownership exceeding five percent of total assets or capital stock) in their company, if they employ or contract with County officials, or if they are former County employees with less than one year of inactive service. The statement applies to the 26Q-073 Tourism Photography and Video contract opportunity, which requires the selected firm to provide comprehensive creative services including photography, videography, and video production to promote Marion County as a tourism destination.
Part 2 of the form addresses advisory board member waivers under Florida Statute 112.313(12), requiring respondents to indicate whether they will request such a waiver or confirm that a waiver is not applicable. The County reserves the right to review any relationships that may be prohibited under the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or otherwise exempt. All photographs and videos produced under the contract become the property of Marion County, with deliverables required within 14 days of shoots and occasional expedited five-day turnarounds for high-resolution content.
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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:
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