2-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-112
- 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 Marion County contract opportunity for the Rainbow Lakes Estates Ivy Place Road Improvement Project. The form requires respondents to disclose any potential conflicts of interest, including employment relationships with county personnel, family connections to county employees or advisory board members, material ownership interests in the responding company held by county officials, or employment of county personnel by the respondent. Respondents must also indicate whether they are former Marion County Board of County Commissioners (MCBCC) employees with less than one year of inactive service, or state that none of the listed conflicts apply.
The form requires respondents to declare their company name, provide printed names and signatures of authorized representatives, and specify whether they will request an advisory board member waiver under Florida Statute 112.313(12). The County reserves the right to review any relationships that may be prohibited under the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or determined to be exempt. Completion and submission of this conflict of interest disclosure is mandatory for all bidders on this road improvement project, which involves reclamation and widening of Ivy Place Road from 18 to 20 feet, limerock importation, swale excavation and grading, and associated drainage improvements.
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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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