1-Conflict of Interest Statement Form.pdf

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: