5-Conflict Of Interest Statement.pdf
PDF 1 MB Posted
- Attached to
- 26P-053 Long Range Tourism Plan 2027-2031
- Solicitation number
- 26-053
- Issued by
- Marion County, Orlando City, Florida
About this file
This is a Conflict of Interest Statement form required by Florida Statute 112.313 for vendors responding to Marion County contract opportunities. The document is designed to identify potential conflicts of interest between respondents and Marion County employees, public officers, or advisory board members. The form requires respondents to disclose whether they or their principals have any direct or indirect relationships with County officials, including employment relationships, ownership interests exceeding five percent of business assets, spousal or familial connections, or prior employment with Marion County within one year of submission. The statement also addresses whether respondents will request an advisory board member waiver under Florida Statute 112.313(12).
The form must be completed and signed by representatives of the responding company and includes checkboxes for various conflict scenarios and waiver requests. Marion County reserves the right to review any disclosed relationships against Florida Ethics Code requirements and will disqualify vendors whose conflicts are not waived or otherwise exempt from the statute's prohibitions. Failure to accurately disclose conflicts or provide required waivers may result in bid disqualification.
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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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