7c- City of Delray Beach - Vendor or Contractor Conflict of Interest Disclosure Statement Information and Instructions rev. 9.21.24.pdf

Vendor or Contractor Conflict of Interest

Disclosure Statement

Information and Instructions

The award of this contract is subject to the provisions of Chapter 112, Part III, Florida Statutes. The City of Delray Beach, Florida, requires this disclosure statement to be completed and filed with all proposals, bids responses, contracts, or grant or loan requests to the City. The disclosure statement is not required for contracts for gas, water, and electric services where no competition exists, or where rates are fixed by law or ordinance. In circumstances where a contract is awarded by competitive bid, the disclosure statement shall be required from persons submitting responses to requests for proposals, requests for qualifications, invitation to bid, grant applications, or other proposals.

A copy of the disclosure statement shall be maintained by the Purchasing Department.

The City of Delray Beach shall not enter into any contract or appropriate any public funds with any person who refuses to provide information required on the disclosure form.

Any person who provides misleading or incorrect information on the disclosure statement shall be disqualified from participation. Also, the contract or grant shall be voidable by the City if the misleading or incorrect information on the disclosure statement is discovered by the City subsequent to execution of a contract.

Definitions

"Business Entity" means any corporation, partnership, limited partnership, proprietorship, firm, enterprise, franchise, association, self-employed individual, or trust, whether fictitiously named or not, doing business in the State of Florida.

"Family, or Family Members, or Familial Relationship" means included but limited to individuals who are related to a public official as father, mother, son, daughter, brother, sister, husband, wife, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, half brother, half sister, person who is engaged to be married to a public official or who otherwise holds himself or herself out as or is generally known as the person whom a public official intends to marry or with whom a public official intends to form or has formed a household.

“Person” means an individual, firm, partnership, association, joint venture, cooperative, or corporation, or any other group or combination acting in concert.

“Public Official” means a person either elected to a governmental position, or appointed to a governmental position who is authorized by statute, resolution or charter to exercise part of the sovereign power of the governmental entity and whose duties of involve the exercise of discretion on behalf of the governmental entity. This also includes all City Employees.

Instructions

Complete all lines as indicated. If an item does not apply, denote N/A (not applicable). If you cannot include required information in the space provided, attach additional sheets as necessary.

CITY OF DELRAY BEACH

VENDOR OR CONTRACTOR CONFLICT

OF INTEREST DISCLOSURE FORM

ENTITY COMPLETING FORM

ADDRESS

CITY, STATE, ZIP TELEPHONE NUMBER

CONTACT EMAIL ADDRESS CELL PHONE NUMBER

This form is provided with:

Invitation to Bid Request for Proposal / Qualifications Proposal Grant or Loan Other

1. Has your business entity or any of your business entities’ partners, divisions, or any related business entity previously performed work or provided goods or services to any City Department within the current or last fiscal year?

Yes No

If yes, identify below the City Department that received the goods or services, the type(s) of goods or services previously provided, and the amount received for the provision of such goods or services. (Use additional pages if necessary)

2. Has your business entity or any of your business entities’ partners, divisions, or any related business entity previously applied for and received any grants or loans from any City Department within the current or last fiscal year?

Yes No

If yes, identify the City Department that awarded the grant or loan, the date such grant or loan was awarded, and the amount of the grant or loan.

CITY DEPARTMENT TYPE OF GOODS/SERVICES AMOUNT RECEIVED

CITY DEPARTMENT DATE GRANT AWARDED AMOUNT OF GRANT OR LOAN

3. List below the name(s) and address(es) of all public officials with whom your business entity, or members of your immediate family have a familial relationship. Identify the office the public official holds or the City Department for which the public official works. (Attach additional sheets if necessary.)

4. List below the name(s) and address(es) of all family members of public officials with whom your business entity, or members of your immediate family have a familial relationship. Identify the office the public official holds or the City Department for which the public official works. (Attach additional sheets if necessary.)

NAME OF NAME OF PUBLIC OFFICIAL/ CITY DEPARTMENT

FAMILY MEMBER ADDRESS PUBLIC EMPLOYEE WHERE EMPLOYED

If you identified individuals in items one and / or two above, describe in detail below the direct benefit to be gained by the public officials, and/or their family members as the result of the contract, proposal, request for proposal, invitation to bid, or grant proposal. (Attach additional sheets if necessary.)

List below the name(s) and address(es) of all paid consultants and/or lobbyists utilized to used in preparation of , request for proposal or qualifications, invitation to bid, or grant or loan proposal:

List below the name(s) of any officer, director, or agent of the Business Entity who is also an employee of the City of Delray Beach.

List below the name(s) of any Public Official who owns, directly or indirectly, an interest of more than five percent (5%) in the Business Entity or any of its parent company or subsidiaries.

NAME OF OFFICER, DIRECTOR, OR AGENT WHO IS ALSO AN EMPLOYEE OF THE CITY

NAME OF ANY PUBLIC OFFICIAL WHO OWNS INTEREST IN BUSINESS ENTITY

NAME OF PUBLIC OFFICIAL/EMPLOYEE ADDRESS CITY DEPARTMENT

NAME OF PAID CONSULTANT/LOBBYIST ADDRESS

List below the name(s), titles and address(es) of all relatives of public officials of the City of Delray Beach having any direct or indirect financial interest of 5% or more in the Business Entity (other than a relationship described in response to paragraphs above), state to whom and how they are related, and describe the nature and extent of the financial interest.

Please check one of the following statements and attach additional documentation if necessary:

_________ To the best of my knowledge, the Business Entity has no potential conflict of interest due to any other clients, contracts, or property interest.

_________ The undersigned firm, by attachment to this form, submits information which may be a potential conflict of interest due to other clients, contracts, or property interests.

By signing below, I certify under oath and penalty of perjury that all statements on or attached to this form are true and correct to the best of my knowledge. I further understand that omissions shall be cause for disqualification from participation in the proposed transaction.

Signature Date

Printed Name Title

NAME OF ANY PUBLIC OFFICIAL’S RELATIVE WHO OWNS AN INTEREST OF 5% OR MORE IN BUSINESS ENTITY