5-2. Vendor Conflict of Interest Form.pdf
PDF 1 MB Posted
- Solicitation number
- IFB-079-26-KM
- Issued by
- Leon County, Florida
About this file
This is a Vendor Conflict of Interest Form required by the City of Tallahassee for the Annual Dielectric Inspection and Testing of Fleet Equipment contract opportunity in Florida. The form requires vendors to disclose any current or reasonably foreseeable conflicts of interest with the City of Tallahassee across six distinct categories. Vendors must respond to each statement with "Yes," "No," or "None Known," with affirmative responses requiring attached explanations. The form applies to potential conflicts including employment of current or former City employees or public officials, material financial interests held by City personnel in the vendor, payments or provisions of value that could influence City decision-making, unfair competitive advantages, and conflicts between services provided to the City and activities of affiliated entities.
The form defines key terms including "Authorized Representative," "Relative," and "Material Personal Financial Interest," with the latter specified as ownership of more than five percent of total assets or capital stock. An authorized representative of the vendor must sign the form, certifying under penalty of law that all information provided is true and complete to the best of their knowledge. The vendor must provide their company name, the representative's name, position title, email address, and phone number. The City of Tallahassee uses this disclosure mechanism to avoid, neutralize, or mitigate significant potential or actual organizational conflicts of interest, though answering "Yes" to any item does not necessarily disqualify a vendor from consideration.
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Text version
5/2020
Vendor Conflict of Interest
Vendors are responsible for disclosing a current or reasonably foreseeable conflict of interest involving the City of Tallahassee. The City of Tallahassee seeks to avoid, neutralize, or mitigate significant potential or actual organizational conflicts of interest. Respond to each of the six statements in the boxes below. Answering “Yes” will not necessarily disqualify a Vendor.
Select “Yes” if a potential conflict of interests exists or if you are uncertain whether a particular circumstance constitutes a potential conflict of interest. If ‘Yes’ is selected, you must provide an explanation on a separate document and attach to this form.
Select “No” if a potential conflict of interest does not exist.
Select “None known” only if (a) it is unduly burdensome to discover the correct response for reasons such as your workforce is so large that it is unreasonable to ascertain whether any potential conflict of interest exists and (b) you in fact do not have knowledge of any potential conflict of interest. If None Known is selected, provide an explanation on a separate document and attach to this form. The explanation must describe why it is unduly burdensome to answer Yes or No.
Yes No None Known
Potential Conflict of Interest
1. Employment by Vendor of a current City of Tallahassee employee or public official, or their family.
2. Employment by Vendor of a former City of Tallahassee public official, manager, department director.
3. Direct or indirect ownership of material personal financial interest in Vendor by a City of Tallahassee employee, public official or their family.
4. A past, present, or foreseeable payment or provision of anything of value by Vendor to a City of Tallahassee employee, public official or their family that could reasonably appear to influence the employee’s or public official’s actions or judgement.
5. An unfair competitive advantage existing in favor of Vendor with regard to a City of Tallahassee contract for which Vendor is competing.
An unfair competitive advantage exists when the vendor competing for award of a contract obtained either (i) access to information that is
Vendor Conflict of Interest
5/2020 not available to the public and which would assist the vendor in obtaining the contract or (ii) source selection information that is relevant to the contract but is not available to all competitors and that would assist the vendor in obtaining the contract.
6. Vendor, through any affiliates, subsidiaries, o other ongoing business relationships, has a potential or actual conflict between services that may be provided by Vendor to Citizens and the activities of the affiliate, subsidiary, or ongoing business relationship.
DEFINITIONS:
Authorized Representative means representative of the vendor with knowledge of vendor’s operations and personnel sufficient to in good faith provide potential conflict of interest information on behalf of the vendor as detailed above.
Relative means father, mother, son, daughter, husband, wife, brother, sister, father-in-law, mother-in-law, son-in-law or daughter-in-law, cousin, niece, nephew and step-children.
Material Personal Financial Interest in a vendor means any position as owner, proprietor, manager, partner (active or silent), officer, director, shareholder or beneficiary of such vendor. A material personal financial interest does not, in most instances, pertain to ownership of a limited number of shares in publicly held firms, shares owned through a mutual fund, or personal bank accounts.
However, direct or indirect ownership of more than five (5) percent of the total assets or capital stock of a vendor constitutes a material personal financial interest in such vendor.
SIGNATURE: By my signature below, I certify that I am an Authorized Representative of the Vendor named below, and that all of the information provided above is true and complete to the best of my knowledge:
Print Vendor Name Print Position Title
Print Your Name Email Address and Phone Number
Signature and Date
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