3-D. CONFLICT OF INTEREST STATEMENT FORM.pdf
PDF 1 MB Posted
- Solicitation number
- 26Q-033
- 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 the Marion County Office of the County Engineer's stormwater engineering design support services contract opportunity (26Q-033). 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. Respondents must disclose whether they are county employees or board members, whether they are spouses or children of such individuals, whether any county official or their family holds a material interest (defined as more than five percent ownership) in the respondent company, whether the respondent employs or contracts with county officials, or whether the respondent's principal or agent is a former county employee with less than one year of inactive service.
The form requires respondents to indicate which conflict categories, if any, apply to their situation and to specify whether they will request an advisory board member waiver under Florida Statute 112.313(12). Marion County reserves the right to review all identified relationships against the Florida Ethics Code and to disqualify any vendor whose conflicts cannot be waived or are not exempt. The completed form must be signed by an authorized company representative and submitted with all required company and personal identification information.
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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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