Attach D - Conflict of Interest.pdf
PDF 16 KB Posted
- Attached to
- Court Reporting
- Solicitation number
- RFSQ-05090
- Issued by
- Broward County, Fruitville CDP, Florida
About this file
This document is a Conflict of Interest Disclosure Form for a state and local contract opportunity related to Court Reporting services in the 17th Judicial Circuit Court of Florida, including Broward County and the City of Fort Lauderdale. The form requires the signatory to certify that they have the legal authority to represent the firm, that no employee or officer of the Court owns an interest of 5% or more in the firm, and that there are no conflicts of interest. The contract opportunity is for multiple vendors to provide court reporting services, with assignments at the discretion of the Judges and Court administration staff. The contract is not a guarantee of work, but will establish the terms and conditions if work is assigned.
The document does not provide details on pricing terms, set asides, incumbents, funding requirements and sources, or other salient information. It is focused solely on the conflict of interest disclosure requirements for the prospective vendors.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attach A - Sup Ct AOSC11-22.pdf | ||
| Attach B - 17th Cir AO 2020-9-Gen.pdf | ||
| Attach C - Staff Roster.pdf | ||
| 2200-23-002-RFQu-Court Reporting 17th v1.pdf |
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Text version
Exhibit “D”
Conflict of Interest Disclosure Form
I HEREBY CERTIFY that:
1. I _____________________________________ (name) am the _____________________
(title) and the duly authorized representative of (firm name) _______________________ whose address is __________________________________________________________
____________________________________________________________________; and
2. I possess the legal authority to make this affidavit on behalf of myself and the firm for which I am acting; and,
3. Except as listed, no employee or officer of the Court owns an interest of 5% or more in the firm, and no employee, officer, or agent of the firm has any conflict of interest, real or apparent, due to ownership, other clients, contracts, or interests associated with this project, and,
4. This proposal is made without prior understanding, agreement, or connection with any other corporation, firm, or person submitting a proposal for the same services, and is in all respects fair and without collusion or fraud.
5.
EXCEPTIONS: (Attach list of exceptions) (if none, so state)
Signature Printed Name
Firm Name Date
STATE OF FLORIDA
COUNTY OF _____
Sworn to (or affirmed) and subscribed before me by means of [ ] physical presence or [ ] online notarization, this _____ day of _________, 2023, by _________________________________.
Signature of Notary
Name of Notary Typed, Printed, or Stamped
Personally Known _____________ OR Produced Identification ______ Type of Identification Produced ____________________________
| title and the duly authorized representative of firm name: |
| name am the: |
| undefined: |
| and: |
| 2 I possess the legal authority to make this affidavit on behalf of myself and the firm for: |
| Firm Name: |
| Sworn to or affirmed and subscribed before me by means of physical presence or online: |
| notarization this: |
| 2023 by: |
| undefined_2: |
| Name of Notary Typed Printed or Stamped: |
| Type of Identification Produced: |
| OR Produced Identification: |
| undefined_3: |
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