1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-089
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for respondents to the Marion County Parks & Recreation contract opportunity 26B-089 for Belleview Sportsplex Soccer Field Restoration. The form requires disclosure of any conflicts of interest between the respondent and Marion County employees, public officers, or advisory board members. Respondents must indicate whether they are county employees or advisory board members, related to such individuals, have officers or partners with material interests in the respondent organization, employ county officials, or are former MCBCC employees with less than one year of inactive service. The form also requires respondents to identify 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 the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or deemed exempt. All respondents must complete the form with printed name, company name, and signature, with additional space provided for multiple named individuals to provide their own signatures and disclosures. Failure to properly disclose conflicts or obtain necessary waivers may result in vendor disqualification from the procurement 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:
| 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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