2-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Attached to
- 26B-057 NE 148th Terrace Bridge Repair
- Solicitation number
- 26-057
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement form required by Florida Statute 112.313 for entities responding to a Miami-Dade County contract opportunity for the NE 148th Terrace Bridge Repair project. The form establishes compliance requirements for respondents to disclose any potential conflicts of interest related to their involvement with county employees, public officers, or advisory board members. Respondents must indicate whether they or their principals have any direct or indirect financial interests in the county, are employed by or contract with county personnel, or have other relationships that could create conflicts under Florida's ethics code. The form also requires respondents to declare whether they will request an advisory board member waiver under Florida Statute 112.313(12).
The form serves as a mandatory disclosure document that allows the county to review vendor relationships and disqualify any respondent whose conflicts are not waived or deemed exempt under applicable law. Respondents must provide their company name, printed name, and signature, along with identification of any relevant county connections or relationships. The county retains the authority to determine whether disclosed conflicts comply with the Florida Ethics Code and whether any requested waivers will be granted prior to vendor selection and contract award.
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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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