1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Attached to
- 27B-010 Water Wagon Trailer
- Solicitation number
- 27-010
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for vendors bidding on Marion County Fleet Management's request for bids on a Water Wagon Trailer (Contract 27B-010). The form requires respondents to disclose any conflicts of interest, including employment relationships, financial interests, or other material connections to Marion County employees, public officers, or advisory board members. The apparatus being procured is a complete, independently powered, removable water distribution system mounted on a 20-foot ISO container-style flat skid with twistlock corner fittings for use on the County's truck-mounted container carrier. The equipment will support municipal road maintenance, dust suppression, road watering, cleaning, and authorized emergency water distribution operations.
Respondents must indicate in Part 1 whether they meet any of the specified conflict criteria, including direct employment with the County, spousal or familial relationships to County officials, material ownership interests in the responding company by County personnel, employment of County personnel by the respondent, or recent separation from County employment. Part 2 requires vendors to state 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 under the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or exempt from the competitive process.
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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:
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