1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Attached to
- 27P-008 Tire Repairs & Service
- Solicitation number
- 27-008
- Issued by
- Marion County, Florida
About this file
This file is a Conflict of Interest Statement Form required by Florida Statute 112.313 for the Marion County tire repairs and service contract opportunity (27P-008). The form is designed to identify potential conflicts of interest for respondents bidding on Marion County Fleet Management's solicitation for tire-related services, including tire repair, mounting, balancing, rotation, and related services for county-owned vehicles and equipment. Respondents must disclose whether they are county employees, public officers, advisory board members, or have family relationships to such individuals, or whether such individuals have material interests in the respondent company. The form also requires disclosure if the respondent employs county officials or if a principal or agent is a former Marion County employee with less than one year of inactive service.
Part 2 of the form requires respondents to indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12) or state that no waiver request is applicable. The county reserves the right to review any relationships that may be prohibited under the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or exempt. All respondents must provide their company name, printed name, and signature to certify the accuracy of their conflict of interest disclosures as part of their bid submission for this tire services contract.
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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 .