Appendix_B_Statement_of_Affirmation_and_Intent.pdf
PDF 141 KB Posted
- Attached to
- Equitable Services for Private Schools
- Solicitation number
- 019-MJ-0326
- Issued by
- Polk County, Florida
About this file
This is an Appendix B Statement of Affirmation and Intent form for the School Board of Polk County, Florida's Request for Proposals (RFP) for Equitable Services for Private Schools. The RFP seeks experienced and qualified proposers to deliver instructional programs including tutoring in reading, mathematics, science, and academic counseling to eligible students in private schools, provide professional development to private school teachers, and conduct parent involvement activities for parents of eligible Title I participants. Respondents are required to propose all three service components. The procurement may result in a single source award.
The Statement of Affirmation and Intent is a notarized certification document that respondents must complete and submit with their proposals. It requires the authorized representative to affirm that the proposal is fair and free from fraud, collusion, and restraint of competitive pricing. Respondents must certify that no School Board members, directors, or employees have direct or indirect financial interests in the bidding entity, and that no ownership or management members are applying for employment or elected positions with the District. The form also requires respondents to confirm they have examined the solicitation documents and agree to meet or exceed the stated scope of services, requirements, and standards. Respondents must further commit to immediately notifying the District in writing if any conflict of interest is identified during service provision. The document must be executed before a notary public.
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Text version
Appendix B 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, Florida (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:
Statement of Affirmation and Intent
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