2-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-126
- 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 Marion County contracts. The form requires respondents to disclose any direct or indirect relationships with County employees, public officers, or advisory board members that could create conflicts of interest, including employment relationships, ownership interests exceeding five percent of business assets, or family connections. Respondents must certify whether they fall under any of the prohibited categories listed or whether none of the conflict scenarios apply. The form also requires respondents to indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12), with the County retaining the authority to review and disqualify vendors whose conflicts are not waived or exempt.
The form requires completion by the company respondent with printed names, signatures, and company identification. Marion County will conduct ethics review of any reported relationships or conflicts prior to contract award. This disclosure requirement applies to the SW 38th Avenue/SW 3rd Street/SW 40th Avenue Resurfacing Project in Florida, which involves milling, resurfacing, pavement marking installation and restriping, and roadway shoulder sodding. Vendors must complete this conflict of interest certification as part of their response to the solicitation, with non-disclosure or unwaived conflicts potentially resulting in bid disqualification.
View the file
Other files
Show all 15
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .