Attachment F.pdf
PDF 186 KB Posted
- Attached to
- Senior Community Service Employement Program
- Solicitation number
- RFP-11545
- Issued by
- Leon County, Florida
About this file
This is a Conflict of Interest Disclosure form (Attachment F) for DOEA Solicitation No. 24-RFP-001-JT from the Florida Department of Elder Affairs (DOEA). The document requires respondents to disclose any potential conflicts of interest related to the procurement process, specifically requiring disclosure of any officers, directors, employees, or agents who are also officers or employees of DOEA, the State of Florida, or its agencies.
The form requires three specific disclosures: 1) identification of any persons who are both officers/directors/employees/agents of the respondent's firm and state officers/employees, 2) names of any state officers or employees who own more than 5% interest in the respondent's firm, and 3) names of any persons who have sought to influence DOEA in this procurement on behalf of the respondent, including employees, agents, lobbyists, or previous DOEA employees who have received or will receive compensation for influence. The form must be signed by an authorized representative who has the authority to bind the respondent.
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Text version
DOEA Solicitation No.: 24-RFP-001- JT Page 1 of 1
ATTACHMENT F
DISCLOSURE STATEMENT
CONFLICT OF INTEREST DISCLOSURE
The award hereunder is subject to the provisions of Chapter 112, F.S.. Respondents must disclose with their proposals whether any officer, director, employee or agent is also an officer or an employee of DOEA, the State of Florida, or any of its Agencies. All firms must disclose the name of any state officer or employee who owns, directly or indirectly, an interest of more than five percent (5%) in the Respondent’s firm or any of its branches or affiliates. All Respondents must also disclose the name of any employee, agent, lobbyist, previous employee of DOEA, or other person, who has received or will receive compensation of any kind to seek to influence the actions of DOEA in connection with this procurement, or who has registered or is required to register under Section 112.3215, F.S., in connection with this procurement.
The following persons are officers, directors, employees, or agents of Respondent’s firm and state officers or employees:
The following persons are state officers or employees who own, directly or indirectly, more than a 5% interest in the
Respondent’s firm:
The following persons have sought to influence DOEA in this procurement on behalf of the Respondent:
The Respondent has no interest to disclose and has had no person seeking to influence DOEA in connection with this procurement.
*Authorized Representative’s Signature
*Typed Name and Title of Authorized Representative
*This individual must have the authority to bind the Respondent.
File details come from the government source that posted it. Updated .