1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-123
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for Marion County Solid Waste's competitive sealed proposal process to lease, design, construct, operate, and maintain a commercial recreational venue on the Martel Closed Landfill. The form requires respondents to disclose any potential conflicts of interest, including direct employment or advisory board positions with Marion County, familial relationships to county employees or officials, material interests exceeding five percent ownership in the respondent entity held by county officials or their relatives, employment or contracting relationships between respondents and county officials, or prior employment with Marion County Board of County Commissioners within the past year. Respondents must indicate which, if any, of these conflict categories apply by providing names of affected individuals and their relationship to the respondent.
The form also requires respondents to declare whether they will request an advisory board member waiver under Florida Statute 112.313(12). Marion County reserves the right to review all disclosed relationships against the Florida Ethics Code and will disqualify any vendor whose conflicts cannot be waived or exempted. Respondents must complete all required fields including company name, printed name, and signature, with the county using this disclosure as a screening mechanism to ensure vendor eligibility prior to proposal evaluation.
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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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