1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-105
- 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's solicitation for a Construction Manager at Risk (CMaR) for the construction of three to four new fire stations. The form requires respondents to disclose any relationships with County employees, public officers, or advisory board members that may create conflicts of interest, including direct employment relationships, family connections to County personnel, material ownership interests in the respondent company held by County officials or their families, or employment of County personnel by the respondent. Respondents must also indicate whether they were formerly employed by Marion County Board of County Commissioners (MCBCC) within the past year and declare whether they will request an advisory board member waiver under Florida Statute 112.313(12).
The form requires the respondent company name, printed name and signature of the authorized representative, and checkboxes to indicate which conflict of interest categories, if any, apply to the submission. The County reserves the right to review all disclosed relationships against the Florida Ethics Code and will disqualify any vendor whose conflicts have not been waived or deemed exempt under applicable law. Completion and accurate disclosure of this form is a mandatory requirement for bid consideration.
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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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