1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-116
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for the Marion County Board of County Commissioners (MCBOCC) solicitation for Workers' Compensation Third-Party Administration Services (26P-116). The form addresses potential conflicts of interest involving public officers, employees, advisory board members, and their immediate family members in relation to respondent firms seeking to contract with the County. Respondents must disclose any direct employment relationships with the County, spousal or child relationships to County personnel, material interests (direct or indirect ownership exceeding 5 percent) in the respondent firm held by County officials or their families, or instances where the respondent employs or contracts with County personnel. Additionally, respondents must disclose if a principal or agent is a former MCBOCC employee with less than one year of inactive service.
The form requires respondents to indicate whether any of the specified conflict categories apply and 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 be prohibited under the Florida Ethics Code and will disqualify vendors whose conflicts are not waived or determined to be exempt. All respondents must provide company identification, printed name, and signature of an authorized representative to certify the accuracy of their conflict of interest disclosures.
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| 7-3 year WC claim history.xlsx | XLSX spreadsheet | |
| 6-Evaluation Process and Scoring Criteria.pdf | ||
| 5-Scope of Work.pdf | ||
| 2-RFx - General Terms and Conditions.pdf | ||
| 3-Vendor Information Form.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: |
File details come from the government source that posted it. Updated .