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5 of 10 <br />C O N F L I C T O F I N T E R E S T <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles each, FL 33160 <br />Telephone: (305) 947-0606 Fax: (305) 949-3113 <br />CONFLICT OF INTEREST STATEMENT <br />The award of any contract hereunder is subject to the provisions of Chapter 112, Florida State Statutes. Proposers <br />must disclose with their Bids, the name of any officer, director, partner, associate or agent who is also an officer or <br />employee of the City of Sunny Isles Beach or its agencies. <br />STATE OF FLORIDA <br />COUNTY OF ________________________ <br />BEFORE ME, the undersigned authority, personally appeared __________________________________________ , <br />who was duly sworn, deposes, and states: <br />18.1. I am the _________________________ of __________________________________________ with a local <br />office in ______________________________________________________________________ and principal office <br />in ___________________________________________________________________________________________. <br />18.2. The above named entity is submitting a Bid for the City of Sunny Isles Beach, Bid No. _________________ <br />described as _________________________________________________________. The Affiant has made diligent <br />inquiry and provides the information contained in this Affidavit based upon his own knowledge. <br />18.3. The Affiant states that only one submittal for the above Bid is being submitted and that the above <br />named entity has no financial interest in other entities submitting Bids for the same project. <br />18.4. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement, <br />participated in any collusion, or otherwise taken any action in restraints of free competitive pricing in connection <br />with the entity’s submittal for the above Bid. This statement restricts the discussion of pricing data until the <br />completion of negotiations if necessary and execution of the Contract for this project. <br />18.5. Neither the entity nor its affiliates, nor anyone associated with them, is presently suspended or <br />otherwise ineligible from participation in contract letting by any local, State, or Federal Agency. <br />18.6. Neither the entity, nor its affiliates, nor anyone associated with them have any potential conflict <br />of interest due to any other clients, contracts, or property interests for this project. <br />18.7. I certify that no member of the entity’s ownership or management is presently applying for any <br />employee position or actively seeking an elected position with the City of Sunny Isles Beach. <br />18.8. I certify that no member of the entity’s ownership or management, or staff has a vested interest in any <br />aspect of the City of Sunny Isles Beach. <br />18.9. In the event that a conflict of interest is identified in the provision of services, I, on behalf of the above <br />named entity, will immediately notify the City of Sunny Isles Beach. <br />Dated this __________ day of __________________________________, 20____. <br />____________________________________________ ____________________________________ <br />AFFIANT Print or Type Name and Title <br />Sworn to and subscribed before me this __________ day of ______________________________, 20____. <br /> Personally Known, OR <br /> Produced Identification - Type of Identification ____________________________________________ <br />NOTARY PUBLIC STATE OF FLORIDA _______________________________________________________