1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-135
- 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 a Miami-Dade County procurement for engineering services on the NW 44th Avenue Preliminary Engineering Report and Design project. The form requires respondents to disclose any potential conflicts of interest, including direct employment or advisory board membership with the County, familial relationships to County employees or officials, material ownership interests exceeding five percent in the respondent company held by County personnel, employment or contracting relationships between the respondent and County employees, or former employee status with less than one year of inactive service. Respondents must also indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12).
The County reserves the right to review all disclosed relationships against Florida Ethics Code requirements and will disqualify any vendor whose conflicts cannot be waived or exempted. The form requires completion of company information, printed name, signature, and identification of relevant parties involved in any potential conflicts. Submission of this statement is a mandatory component of the procurement process for the NW 44th Avenue project, which involves preliminary engineering and design services for a 1.4-mile roadway corridor expansion from two lanes to four lanes between NW 60th Street and West Highway 326.
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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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