Appendix_A_Statement_of_Affirmation_and_Intent.docx
DOCX document 29 KB Posted
- Attached to
- Employee Benefits Consultant Services
- Solicitation number
- 023-DW-0125
- Issued by
- Polk County, Florida
About this file
Appendix A Statement of Affirmation and Intent is a document from the School Board of Polk County, Florida, related to a solicitation for Employee Benefits Consultant Services. The document serves as a formal declaration by potential vendors affirming the integrity of their proposal submission, with respondents certifying they are submitting a fair, non-collusive bid for consulting services aimed at assisting the district in purchasing insurance products for employees.
The document requires vendors to disclose and avoid potential conflicts of interest, specifically prohibiting board members, directors, or school employees from directly or indirectly owning assets in the bidding entity or benefiting from the proposal's profits. Respondents must also confirm they are not simultaneously applying for district employment or seeking elected positions. The solicitation anticipates compensation will be on a fee-for-service basis, with the primary goal of identifying a consultant who will promote insurance products that best serve the district and its employees' interests.
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Other files
| File | Type | Posted |
|---|---|---|
| 023-DW-0125_Withdrawal.pdf | ||
| Robinson_Bush_contract_FE_05.23.2024.pdf | ||
| 023-DW-0125_Employee_Benefits_Consultant_Services_Addendum1.pdf | ||
| Appendix_C_AD-1048_Cert_debar_susp_inelig_vol_excl.docx | DOCX document | |
| 023-DW-0125_Employee_Benefits_Consultant_Services_ITN.pdf | ||
| Appendix_F_Byrd_Antilobbying_Amendment.docx | DOCX document | |
| Appendix_B_Conflict_of_Interest_Statement.docx | DOCX document | |
| Appendix_E_MWBE-LDB-VBE_Form.docx | DOCX document | |
| Appendix_G_Reference_Request_Form.docx | DOCX document | |
| Appendix_D_Drug_Free_Workplace.docx | DOCX document | |
| Addendum_Acknowledgment_Form.docx | DOCX document |
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Text version
Appendix A Statement of Affirmation and Intent
The undersigned, hereinafter called the respondent, declares that this proposal is, in all respects, fair and without fraud that it is made without collusion with any other vendor or official of the School Board of Polk County (District). Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in connection with the entity’s submittal for the above project.
The respondent certifies that no Board Member, Director, or any School Board Employee directly or indirectly owns assets or capital stock of the bidding entity, nor will directly or indirectly benefit by the profits or emoluments of this proposal.
The respondent certifies that no member of the entity’s ownership or management is presently applying for an employee position or actively seeking an elected position with the District. In the event that a conflict of interest is identified in the provision of services, the respondent agrees to immediately notify the District in writing.
The respondent further declares that he/she has carefully examined the scope of services, instructions, terms and conditions of this solicitation and that respondent’s proposal is made according to the provisions of the solicitation and that he/she will meet or exceed the scope of services, requirements, and standards contained in the solicitation.
Corporate Name of Respondent (Typed) Address, City, Zip
Authorized Representative’s Signature Date Telephone Number
NOTARY PUBLIC:
State Of: County Of:
| On this | day of | , 20 | , before me appeared (name) | sworn, did execute the foregoing document, and did state that he or she was properly authorized by (name of company) |
| , to execute the document and did so as his or her free act and deed. |
Notary Public Signature:
Notary Name, Printed, Typed or Stamped:
Commission Number: ________________ My Commission Expires:
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