1-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Attached to
- 26B-098 Waste Tire Transport & Disposal
- Solicitation number
- 26-098
- Issued by
- Marion County, Florida
About this file
This Conflict of Interest Statement Form is required by Florida Statute 112.313 for all respondents bidding on Marion County Solid Waste's ITB 26B-098 for waste tire transportation and disposal services. The form mandates disclosure of any direct or indirect relationships between the bidding company and County employees, public officers, or advisory board members. Respondents must indicate whether they are County employees, related to County employees, have material interests (defined as direct or indirect ownership exceeding 5% of business assets or capital stock) in the bidding entity, employ County personnel, or are former County employees with less than one year of inactive service. The form requires certification by company representatives and permits requesters to seek advisory board member waivers under Florida Statute 112.313(12) where applicable.
The County reserves the right to disqualify any vendor whose conflicts of interest are neither waived nor exempt under the Florida Ethics Code. All respondents must complete and submit this disclosure form as part of their bid packages through Marion County's Bonfire e-procurement portal by the July 9, 2026 deadline. Failure to accurately disclose conflicts or submission of false information may result in bid rejection and potential legal consequences under Florida's ethics statutes.
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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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