1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-100
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Marion County, Florida, in accordance with Florida Statute 112.313, which governs ethical limitations for public officers, employees, and advisory board members regarding contractual relationships with the County. The form is associated with Marion County's request for qualified vendors to provide pumping, vacuum truck, and high-pressure water jetting services at multiple Solid Waste locations. The contract encompasses routine pumping of leachate tanks, truck wash tanks, condensate tanks, grit tanks, and a wet well, with selected vendors required to provide emergency callout availability and assume responsibility for offsite disposal of all collected material under a two-year initial term with three optional one-year renewals.
The form requires respondents to disclose any conflicts of interest, including whether they are County employees, public officers, or advisory board members; whether they are spouses or children of such individuals; whether any such individuals hold material interests (defined as direct or indirect ownership exceeding 5% of total assets or capital stock) in the respondent company; or whether the respondent employs or contracts with County officials. Additionally, respondents must indicate whether they are former MCBCC employees with less than one year of inactive service and whether they will request an advisory board member waiver under Florida Statute 112.313(12). The County retains the right to disqualify any vendor whose conflicts are not waived or deemed exempt under the Florida Ethics Code.
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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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