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ITB NO. 12-0005 ATTACHMENT C CITIZENS PROPERTY INSURANCE CORPORATION VENDOR CONFLICT OF INTEREST DISCLOSURE FORM DISCLOSURE STATEMENT All VENDORS should be aware of CITIZENS Code of Ethics which prohibits CITIZENS employees and Board of Governors members from having certain relationships with persons or entities conducting or proposing to conduct business with CITIZENS and which prohibits the acceptance of gifts from VENDORS. The entire Code of Ethics may be viewed at www. Citizensfla.com. The Code and its definitions are incorporated by reference into this Disclosure Form. If a VENDOR has a disclosable relationship the VENDOR should disclose any Conflict of Interest or potential Conflict of Interest that may exist. Conflicts of Interest potential or actual will be evaluated by the Director of Purchasing and General Services to determine the proper course of action. Failure to comply with the provisions established above may render the VENDOR ineligible to participate in CITIZENS purchasing process. citizensfla*com* The Code and its definitions are incorporated by reference into this Disclosure Form* If a VENDOR has a disclosable relationship the VENDOR should disclose any Conflict of Interest or potential Conflict of Interest that may exist. Conflicts of Interest potential or actual will be evaluated by the Director of Purchasing and General Services to determine the proper course of action* Failure to comply with the provisions established above may render the VENDOR ineligible to participate in CITIZENS purchasing process. CERTIFICATION I hereby certify that except as disclosed below to VENDOR S knowledge there is no conflict of interest involving the VENDOR named below that would violate the CITIZENS Code of Ethics including that VENDOR does not a knowingly employ a CITIZENS employee or family member b knowingly allow a CITIZENS employee or family member to own or have a material personal financial interest directly or indirectly in the VENDOR or c knowingly engage in material personal business transaction with a VENDOR INFORMATION VENDOR Name VENDOR Phone Number VENDOR Address Federal Identification State of Incorporation or Domicile This form is required for all contracts or individual purchases in the amount of 25 000 or more. CP P Purchasing Form Number 501B Page 1 of 2 Rev* 3-2010 I HEREBY CERTIFY THAT THE VENDOR REFERENCED ABOVE HAS A POTENTIAL CONFLICT OF INTEREST with a CITIZENS employee or Board of Governors member. YES the above statement is true. NO the above statement is not true. If YES please provide the following information LIST the name s of CITIZENS employee s or Board of Governor member s with whom there may be a conflict of interest PROVIDE A BRIEF DESCRIPTION of the nature of the potential conflict s of interest SIGNATURE By my signature below I certify that I am the Authorized Representative of the VENDOR named above and that all of the information provided above is true and complete to the best of my knowledge Print the Name of the VENDOR S Authorized Representative Print the Position Title of the VENDOR S Authorized Representative VENDOR S Authorized Representative s Signature Date.

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