9-Conflict of Interest Certification.pdf
PDF 225 KB Posted
- Solicitation number
- 25/0236
- Issued by
- Harris County, Texas
About this file
This document is a Conflict of Interest Certification form from the Harris County Juvenile Probation Department (HCJPD), dated 06/16/2021. The form is designed to ensure vendors seeking to contract with or respond to a Request for Proposal (RFP) or bid do not have inappropriate business relationships with specific county personnel. Vendors must certify they do not have an employment or business relationship with Harris County Juvenile Board members, Deputy Directors, or their family members that would result in taxable income exceeding $2,500 within a 12-month period.
The form requires vendors to disclose and affirm that they have not provided gifts exceeding $100 in aggregate value to Juvenile Board members, Deputy Directors, or their family members during a 12-month period, as stipulated in sections 176.003 and 176.006 of the Local Government Code. If a vendor cannot certify these statements, they are required to complete a separate Conflict of Interest Questionnaire and follow the additional instructions provided in that document. The form includes spaces for the vendor's name, representative's name, signature, and date of certification.
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Text version
HARRIS COUNTY JUVENILE PROBATION DEPARTMENT
CONFLICT OF INTEREST CERTIFICATION
Form updated: 06/16/2021
Instructions: State law requires vendors who are negotiating to contract or responding to a RFP or bid advertised by the local governmental entity to file a Conflict of Interest disclosure if the vendor has a business relationship with a local governmental officer or a family member of that officer. As a result, HCJPD is requiring vendors to certify the below statements, and if true, fill it out, sign and return this form. Otherwise, the vendor must complete the Conflict of
Interest Questionnaire and follow the instructions found in that form.
This form is to certify that does not have an employment or
Name of Vendor other business relationship with:
a member(s) of the Harris County Juvenile Board;
a Deputy Director(s), or similar individual of the Harris County Juvenile Probation
Department; and/or, a family member(s) of the aforementioned individual(s), that results in the aforementioned individuals receiving a taxable income in excess of $2,500 during a 12-month period. In addition, vendor has not given any Juvenile Board member(s), Deputy Director or similar individual, or family member of the aforementioned individual(s) one or more gifts with an aggregate value in excess of $100 during a 12-month period. (Please see sections 176.003 and 176.006 of the Local Government Code.)
Name of Representative Signature
Date
File details come from the government source that posted it. Updated .