6-6. CONFLICT OF INTEREST STATEMENT FORM.pdf
PDF 1 MB Posted
- Attached to
- 26B-012 GRAPPLE TRAILER
- Solicitation number
- 26B-012
- Issued by
- Marion County, Florida
About this file
This document is a Conflict of Interest Statement form related to Florida Statute §112.313, which applies to county contracts and potential conflicts involving public officers, employees, and advisory board members. The form requires respondents to disclose any potential conflicts of interest across two primary parts: Part 1 solicits information about direct or indirect relationships between the respondent and county employees or officials, including employment status, family connections, ownership interests, and recent employment history. Part 2 addresses whether the respondent will seek an advisory board member waiver under the specified Florida Statute.
The form emphasizes that the county will review all disclosed relationships under the Florida Ethics Code and reserves the right to disqualify vendors with unresolved conflicts of interest. The statement provides checkboxes for respondents to indicate various potential conflict scenarios, such as being a county employee, having a family member employed by the county, owning a significant business interest, or having recent employment connections. The form requires completion of company name, printed name, and signature, serving as a legal declaration of the respondent's potential conflicts or lack thereof.
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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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