Statement_of_Affirmation_and_Intent.pdf
PDF 93 KB Posted
- Attached to
- School Nutrition Consumable Supplies - Stock
- Solicitation number
- 002-RW-0727
- Issued by
- Polk County, Florida
About this file
This is a Statement of Affirmation and Intent form required by the School Board of Polk County, Florida, Purchasing Department for the School Nutrition Consumable Supplies - Stock contract opportunity. The form serves as a certification document that respondents must complete and submit as part of their proposal. The document confirms that the proposing entity's submittal is fair, free from fraud, and made without collusion with other vendors or school district officials. Respondents must affirm that they have carefully examined the scope of services, instructions, terms, and conditions of the Request for Proposal and commit to meeting or exceeding all stated requirements and standards. The form requires the corporate name, address, authorized representative signature, and notarization before submission.
The Statement of Affirmation and Intent requires respondents to certify several conflict-of-interest conditions, including that no Board Members, Directors, or School Board employees directly or indirectly own assets or capital stock in the bidding entity or benefit from its profits. Additionally, respondents must confirm that no members of the entity's ownership or management are applying for employment or seeking elected positions with the District. The form mandates that respondents immediately notify the District in writing if any conflict of interest is identified during service provision. The document must be notarized by a public notary, with the notary's signature, printed name, commission number, and commission expiration date required for execution.
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Text version
Statement of Affirmation and Intent
TO: The School Board of Polk County, Florida, Purchasing Department
PROJECT:
DATE:
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 (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 Request for Proposal and that respondent’s proposal is made according to the provisions of the RFP and that he/she will meet or exceed the scope of services, requirements, and standards contained in the Request for Proposal.
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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