Statement_of_Affirmation_and_Intent.pdf
PDF 89 KB Posted
- Attached to
- Milk, Dairy and Non-Dairy
- Solicitation number
- 002-DW-0326
- Issued by
- Florida
About this file
This is a Statement of Affirmation and Intent form required by the School Board of Polk County, Florida, for vendors responding to a Request for Proposal for the procurement of milk, dairy, and non-dairy products. The document serves as a certification that the respondent's proposal is fair, made without fraud, and submitted without collusion with other vendors or District officials. The respondent must affirm that they have carefully examined the scope of services, instructions, terms, and conditions of the solicitation and will meet or exceed all requirements and standards outlined therein.
The form requires the respondent to certify that no Board members, Directors, or School Board employees directly or indirectly own assets, capital stock, or will benefit from the profits of the bidding entity. Additionally, the respondent must confirm that no members of the entity's ownership or management are applying for employment positions or seeking elected positions with the District. The form requires execution by an authorized representative and notarization, with the notary public providing their signature, printed name, commission number, and commission expiration date. Respondents are obligated to immediately notify the District in writing if any conflict of interest is identified during the provision of services.
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Text version
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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