2-Conflict of Interest Statement Form.pdf

This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for vendors responding to Marion County contract opportunity 26B-095 involving road resurfacing in Marion Oaks Units 9, 10, and 12. The form requires respondents to disclose any relationships with County employees, public officers, or advisory board members that could present conflicts of interest, including direct employment relationships, family connections to County officials, material ownership interests in the responding entity by County personnel, or employment of County staff by the respondent. Respondents must also declare whether they are former Marion County employees with less than one year of inactive service, as such circumstances would prohibit contract award under Florida Ethics Code provisions.

The form contains two primary sections requiring certification: Part 1 requests disclosure of any conflicting relationships or circumstances, with respondents required to identify specific individuals and their relationship to the County if applicable, or certify that none of the listed conflict categories apply; Part 2 requires respondents to indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12) or confirm that such a waiver is not applicable. The County retains the authority to review all disclosed relationships against Florida Ethics Code requirements and will disqualify any vendor whose conflicts cannot be waived or exempted. All responses must include the respondent's company name, printed name, and signature of an authorized representative.