2-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-096
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for respondents to a state and local contract opportunity in Florida. The form is applicable to the 26B-096 Silver Creek and Silver Creek 1st Addition Road Improvement Project, which involves reclaiming and resurfacing approximately 0.91 miles of subdivision local road sections within Silver Creek and Silver Creek 1st Addition, including removal of high shoulders, sod application, thermoplastic striping, maintenance of traffic, and construction layout work. The form requires respondents to disclose any conflicts of interest or relationships with County employees, public officers, or advisory board members that may be prohibited under Florida's Ethics Code.
The form contains two parts requiring disclosure. Part 1 requests identification of any direct conflicts, including whether the respondent is a County employee or public officer, related to County personnel, has material interest in the respondent company, or employs County officials. Part 2 addresses requests for advisory board member waivers under Florida Statute 112.313(12). The County reserves the right to review all disclosed relationships and disqualify any vendor whose conflicts cannot be waived or exempted under applicable law. Respondents must provide company name, printed name, and signature to complete the certification.
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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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