9-12 Conflict Of Interest Statement Form.pdf
PDF 1 MB Posted
- Solicitation number
- 26-094
- Issued by
- Marion County, Florida
About this file
This is a Conflict of Interest Statement Form for the Marion County, Florida stormwater infrastructure project designated 26B-094 Stanton Weirsdale Drainage Retention Area. The form is a standard disclosure document required for bidders and contractors participating in this public works project. The project involves the construction of a new drainage retention area and associated conveyance system on Parcel 49794-000-00, with work occurring within the right-of-way and Marion County-owned parcels along SE 134th Avenue Road. As a mandatory conflict of interest disclosure form, it establishes the foundation for ethical procurement practices and ensures that all parties involved in bidding or contracting for this stormwater retrofit and drainage improvement project certify they have no undisclosed conflicts of interest that would impair their ability to perform work impartially.
The form serves as a compliance and governance mechanism required before a bidder can be considered for contract award on this Marion County drainage improvement project. Completion and submission of the conflict of interest statement is a prerequisite for participation in the competitive bidding process. The document ensures transparency and adherence to Florida public procurement standards, protecting the integrity of the selection process and safeguarding public funds allocated to this stormwater conveyance improvement initiative.
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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:
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| Check Box: Off |
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| PRINTED NAME: |
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