6-CONFLICT OF INTEREST STATEMENT FORM.pdf

1 MB Posted

Attached to
26B-035 GRAPPLE TRAILER
Solicitation number
26B-035
Issued by
Marion County, Florida

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This is a Conflict of Interest Statement Form required by Florida Statute 112.313 for respondents to the Marion County Solid Waste Department's solicitation 26B-035 for two grapple trailers. The form requires vendors to disclose any potential conflicts of interest, including employment relationships with the County, family connections to County employees or advisory board members, material interests in the responding company held by County officials or their relatives, 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 the respondent company name, printed name, and signature of an authorized representative to certify the accuracy of conflict of interest disclosures. The County reserves the right to review all disclosed relationships against the Florida Ethics Code and will disqualify any vendor whose conflicts are not waived or deemed exempt. Submission of this completed form is a standard requirement for participation in Marion County procurement activities and ensures compliance with state ethics regulations governing public contracting.

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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:

File details come from the government source that posted it. Updated .