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 in connection with the 5th District Court of Appeal Security Upgrades project (ITN #2025-002). The form mandates that all interested vendors complete and submit the disclosure to be eligible for contract award. A mandatory pre-proposal conference is scheduled for January 22, 2026, at 10:00 AM, with escorted site visits available January 22-23, 2026, at the courthouse located at 300 South Beach Street in Daytona Beach, Florida. Technical and cost replies are due February 11, 2026, at 4:00 PM, with cost volume opening scheduled for February 25, 2026. The contract will commence on April 10, 2026, with an initial one-year term and potential renewals for up to three additional years based on satisfactory performance.
The disclosure form requires vendors to certify that no OSCA officials, employees, or their immediate family members have ownership interests in the vendor's company or derive personal financial gain from the contract; no retired or separated OSCA employees separated less than one year have ownership interests; no OSCA employees are currently or prospectively employed with the vendor; and no gifts, hospitality, or gratuities of any dollar value have been or will be provided to OSCA employees or elected officials to obtain or maintain the contract. Vendors must disclose any exceptions to these certifications, identifying specific OSCA employees, officials, or immediate family members with whom conflicts may exist and describing the nature of the relationship or interest. Notably, disclosing a potential conflict of interest does not automatically disqualify vendors; however, failure to disclose detected conflicts will result in contract termination. Vendors must submit signed forms certifying the truthfulness and accuracy of all information provided.
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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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