25-84131500-ITN DFS BOR Attachment R Notice of Conflict.pdf
PDF 105 KB Posted
- Attached to
- Insurance Broker of Record - Reinsurance Broker for Property and Casualty lines, Risk Management and
- Solicitation number
- ITN-13124
- Issued by
- St. Johns County, Florida
About this file
This document is a Notice of Conflict of Interest form for Invitation to Negotiate (ITN) No. 25-84131500-ITN, which appears to be related to a state procurement process in Florida. The form is designed to ensure transparency and compliance with Chapter 112 of the Florida Statutes by requiring respondents (vendors) to disclose any potential conflicts of interest during the solicitation process.
The form requires vendors to declare if any of their corporate officers, directors, or agents are currently state employees, or if any current state employees own a significant (5% or more) financial interest in the responding company. Vendors must complete the form by either listing any such conflicts or writing "N/A" if no conflicts exist. The document includes spaces for the respondent's name, details of potential conflicts, the authorized representative's signature, printed name, and the date of submission, serving as a critical component of maintaining ethical standards in the state's procurement procedures.
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Text version
ITN No.: 25-84131500-ITN
ITN No.: 25-84131500-ITN
Attachment R
NOTICE OF CONFLICT OF INTEREST
Respondent (Vendor) Name: ______________________________________________
For the purpose of participating in the solicitation process and complying with the provisions of Chapter 112, F.S., the company states the following conflict(s) of interest exists as noted below (if none, write N/A in the applicable section(s) below):
The persons listed below are corporate officers, directors, or agents of the Respondent and are also currently employees of the State or one of its agencies:
The persons listed below are current employees of the State or one of its agencies who own an interest of five percent (5%) or more in the Respondent:
Signature of Respondent’s Authorized Representative
Authorized Representative’s Printed Name
Date
File details come from the government source that posted it. Updated .