Ethics Form rev 9-27-18 v2.pdf

Revised 09-27-18

ETHICS IN CONTRACTING VENDOR FORM

(DISCLOSURE OF RELATIONSHIPS WITH COUNTY

CONTRACT MANAGERS BY OWNERS AND OFFICERS OF

BUSINESS SUBMITTING QUOTE)

- This form must be completed by a person holding a key position in the business, such as, an officer, director, trustee, partner, senior engineer or sales manager and have influence in making this bid or response or in performing the contract if the County awards it to your business.

- Please fill out this form to the best of your knowledge and belief.

- Detach and make additional copies of this form if needed.

- If you are unsure about what to disclose, contact the Purchasing Division at (313) 224-5151.

- You are not required to question family members beyond what you already know of their affairs.

- Submit this form with your quote/bid/proposal. A copy will be kept on file by the County Clerk & the

Purchasing Director.

- If you fail to fully disclose the required information below, the County may terminate your contract if your business is awarded one.

1. Is any Partner, Principal, Corporate Officer, Owner or Corporate Director an immediate family member of a County employee? YES NO

If Yes: Name: Relationship:

Department: Title:

2. Without any further inquiry, are you aware if your business has employed an immediate family member of a County employee within the previous twelve (12) months? YES NO

If Yes: Name:

3. Without any further inquiry, are you aware if your business has discussed hiring an immediate family member of a contract manager within the past twelve (12) months? YES NO

If Yes: Name of Contract Manager:

4. Does any Partner, Principal, Corporate Officer, Owner or Corporate Director and a contract manager each have a substantial financial interest in one or more of the same business ventures?

YES NO

If Yes: Name of Contract Manager:

Revised 09-27-18

ETHICS

CERTIFICATION

I certify that I have disclosed all information within my knowledge, which is required by this disclosure form.

Name (Please Print):

Signature: Date:

Company Name:

Company Tax ID #:

ETHICS

DEFINITIONS

Contract Manager

An elected or appointed Wayne County official identified as having significant discretion over

County contracts.

Immediate Family

YOUR FATHER, MOTHER, SON, DAUGHTER, BROTHER, SISTER, UNCLE, AUNT, GREAT AUNT,

GREAT UNCLE, FIRST COUSIN, NEPHEW, NIECE, HUSBAND, WIFE, GRANDFATHER,

GRANDMOTHER, GRANDSON, GRANDDAUGHTER, FATHER-IN-LAW, MOTHER-IN-LAW, SON-

IN-LAW, DAUGHTER-IN-LAW, BROTHER-IN-LAW, SISTER-IN-LAW, STEPFATHER,

STEPMOTHER, STEPSON, STEPDAUGHTER, STEPBROTHER, STEPSISTER, HALF BROTHER,

HALF SISTER, AND INCLUDING THE GRANDFATHER OR GRANDMOTHER OF AN

INDIVIDUAL’S SPOUSE. IT SHALL ALSO INCLUDE A FORMER SPOUSE OR AN INDIVIDUAL

WITH WHOM THE PUBLIC SERVANT HAS HAD A CHILD IN COMMON.

Substantial Financial Interest

- Ownership of any interest or involvement in any relationship, which results in the receipt of $500 or more per year. Exceptions: Market-rate from a financial institution; income from the ownership of less than $10,000 of stocks and bonds traded on the national stock exchanges.

- Holding a key position in a business such as officer, director, trustee, partner or sales manager.

Exceptions: Officers who serve without compensation on the boards of charitable organizations.

BUSINESS INFORMATION QUESTIONNAIRE

Please complete the following:

1. Company’s official registered name

2. Brief history of your company, including the year it was established

3. Company’s Dun & Bradstreet (D&B) number (Required for federally funded contracts, optional otherwise)

4. Company Type (Corporation, LLC, Joint Venture, Partnership, Individual). If Corporation, include State of Incorporation and Date of Incorporation.

5. Company’s organizational chart including those individuals that would be involved in the contract. P l e a s e include all Partners, Principals, Corporate Officers or Owners, Corporate

Directors.

6. Corporate office location

a. List the addresses of sales and service offices/locations in Michigan

b. List the names of key contacts at each with title, address, phone and e-mail address

7. List of principal owners / stockholders (i.e., those holding 5% or more of the company or outstanding stock)

8. Financial Disclosure/Conflicts of Interest (Identify any contract(s), including any contract involving an employment or consulting relationship, which the firm, or its partners, principals, corporate officers or owners currently has with Wayne County, or with any of its Commissioners or officers.

9. Has your company been debarred by the Federal, any State or Local Governments or

Authorities? Yes No If yes, has it been lifted and if so, when?

10. Has your company had contracts terminated for breach or failure to perform within the past five years? Yes No If yes, by whom and why?

11. Has your company had any violations, or are there any investigations pending for any Federal, any

State or Local Governmental or Authority contracts? Yes No

If yes, has it been lifted and if so, when?