11-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-040
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for vendors responding to a Request for Proposals issued by Miami-Dade County for Group Dental Insurance Services for Eligible Employees and Dependents (RFP 26P-040). The form requires respondents to disclose any relationships with County employees, public officers, or advisory board members that could create conflicts of interest, including direct employment relationships, family connections, material ownership interests exceeding five percent of business assets, or employment of County personnel. Respondents must also indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12).
The County will review all disclosed relationships against the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or otherwise exempt from restrictions. Completion of this form is mandatory for proposal submission, and respondents must provide their company name, printed name, and signature along with identification of any individuals with potential conflicts, including names of relevant County employees, officers, or board members involved in the relationship.
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| 4-EXHIBIT B - Current Census.xls | XLS spreadsheet | |
| 9-RFx - General Terms and Conditions.pdf | ||
| 6-EXHIBIT D - Top 25 Providers.xlsx | XLSX spreadsheet | |
| 7-EXHIBIT C - Past Three-Year Claims and Enrollment History.xlsx | XLSX spreadsheet | |
| 1-Scope of Services.pdf | ||
| 8-Questionnaire.docx | DOCX document | |
| 5-EXHIBIT A - Current Plan Certificate.pdf | ||
| 2-EXHIBIT F - Current Schedule of Benefits.pdf | ||
| 3-EXHIBIT E - Current Rollover Balance.xlsx | XLSX spreadsheet | |
| 10-Vendor Information Form.pdf |
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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 .