3-D. CONFLICT OF INTEREST STATEMENT FORM.pdf
PDF 1 MB Posted
- Solicitation number
- 26-033
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for respondents bidding on the Hickory Vet Stormwater Retrofit project (Bid No. 26-033) in Harford County, Maryland. The form requires bidders to disclose any conflicts of interest, including employment relationships with county staff, advisory board members, or their immediate family members; ownership interests of more than 5% in the respondent company by county officials or employees; or employment of county personnel by the respondent. Respondents must also indicate whether they will request an advisory board member waiver under Florida Statute 112.313(12). The form requires completion and signature by an authorized company representative, with all disclosed relationships subject to county review for compliance with the Florida Ethics Code. Any vendor whose conflicts cannot be waived or exempted will be disqualified from consideration.
The form serves as a mandatory disclosure document to ensure ethical procurement practices and prevent conflicts of interest in the bidding process. Respondents must certify either that none of the conflict criteria apply or provide detailed information about any relationships that may create ethical concerns. The county reserves the right to deny contract awards to vendors whose disclosed conflicts are not resolved through waiver or exemption under applicable Florida ethics statutes. Completion and submission of this form is a prerequisite for bid acceptance and evaluation.
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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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