3-Conflict of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-047
- 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's Request for Prequalification for Consulting Firms for Feasibility Analysis Services. The form is designed to identify potential conflicts of interest involving county employees, public officers, advisory board members, and their immediate family members who may have direct or indirect financial interests in the responding firm or business relationships with the county. Respondents must disclose whether they are county employees or advisory board members, whether they are family members of such officials, whether any county officials or their families hold material interests (defined as ownership of more than 5 percent of total assets or capital stock) in the respondent company, whether the respondent employs or contracts with county officials, or whether the principal or agent was a former county employee with less than one year of inactive service. The form also requires respondents to indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12).
The county reserves the right to review all disclosed relationships against the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or determined to be exempt under applicable law. Respondents must provide their company name, printed name, signature, and may need to list multiple individuals and their relationships to county officials as applicable to their specific circumstances.
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Other files
| File | Type | Posted |
|---|---|---|
| 1-General Terms and Conditions.pdf | ||
| 2-Vendor Information Form.pdf | ||
| 5-Scope of Services.pdf | ||
| 4-Scoring Criteria and Evaluation Process.pdf |
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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: |
File details come from the government source that posted it. Updated .