Vendor Conflict of Interest Disclosure Form.pdf
PDF 171 KB Posted
- Attached to
- 5th District Court of Appeal Security Upgrades
- Solicitation number
- ITN-14562
- Issued by
- Leon County, Florida
About this file
This is a Vendor Conflict of Interest Disclosure Form required by the Office of the State Courts Administrator (OSCA) for all vendors seeking to conduct business with the agency. The form must be completed and returned by all vendors to be eligible for contract awards related to the 5th District Court of Appeal Security Upgrades project in Daytona Beach, Florida. Vendors are required to certify compliance with OSCA's conflict of interest policies and disclose any relationships with OSCA officials, employees, or their immediate family members that could present conflicts of interest.
The form requires vendor certification in five key areas: that no OSCA official, employee, or immediate family member has ownership interest in the vendor's company or derives personal financial gain from the contract; that no retired or separated OSCA official or employee who separated within the past year holds ownership interest in the vendor's company; that no OSCA employee is currently or prospectively employed by the vendor; that the vendor has not provided and will not provide gifts, hospitality, or gratuities of any value to OSCA employees or officials to obtain or maintain contracts; and disclosure of any exceptions to these certifications. The form includes a signature section for an authorized vendor representative and specifies that while disclosure of potential conflicts does not automatically disqualify vendors, failure to disclose detected conflicts will result in contract termination.
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Vendor Conflict of Interest Disclosure Form
All vendors interested in conducting business with the Office of the State Courts Administrator (OSCA) must complete and return the Vendor Conflict of Interest Disclosure Form in order to be eligible to be awarded a contract. Please note that all vendors are subject to comply with the OSCA’s conflict interest policies as stated within the certification section below.
If a vendor has a relationship with an OSCA official or employee, an immediate family member of an OSCA official or employee, the vendor shall disclose the information required below.
Certification: I hereby certify that to my knowledge, there is no conflict of interest involving the vendor named below:
1. No OSCA official or employee or employee’s immediate family member has an ownership interest in vendor’s company or is deriving personal financial gain from this contract.
2. No retired or separated OSCA official or employee who has been retired or separated from the OSCA for less than one (1) year has an ownership interest in vendor’s Company.
3. No OSCA employee is contemporaneously employed or prospectively to be employed with the vendor.
4. Vendor hereby declares it has not and will not provide gifts or hospitality of any dollar value or any other gratuities to any OSCA employee or elected official to obtain or maintain a contract.
5. Please note any exceptions below.
Vendor Name Vendor Telephone Number
Conflict of Interest Disclosure
Name of OSCA employees, officials, or immediate family members with whom there may be a conflict of interest.
Relationship, Interest, Other Conflict
*Disclosing a potential conflict of interest does not disqualify vendors. In the event vendors do not disclose a potential conflict of interest and they are detected by the OSCA, the resulting contract will be terminated.
I certify that the information provided is true and correct by my signature below.
Name of Vendor Authorized Representative Signature of Authorized Representative Date
| Vendor Telephone Number |
| Vendor Name |
| Conflict of Interest Disclosure |
| Name of OSCA employees, officials, or immediate family members with whom there may be a conflict of interest. |
| Relationship, Interest, Other Conflict |
| *Disclosing a potential conflict of interest does not disqualify vendors. In the event vendors do not disclose a potential conflict of interest and they are detected by the OSCA, the resulting contract will be terminated. |
| I certify that the information provided is true and correct by my signature below. |
| __________________________ ________________________________ ___________ |
| Name of Vendor Authorized Representative Signature of Authorized Representative Date |
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