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DISCLOSURE AFFIDAVIT The City of Deerfield Beach requires (Deerfield Beach, FL)

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For Office Use Only
Date:
Application
Nos.:
DISCLOSURE AFFIDAVIT
The City of Deerfield Beach requires all applicants, and persons and/or
entities doing business with the City, to disclose any potential for or conflict
of interest as stated below. Per Ordinance No. 2009/006 of the City of
Deerfield Beach, the adopted Ethics Code contains the following:
Section 5. Disclosure and Behavior Requirements of Applicants and Persons/Entity
seeking a City contract or currently doing business with the City.
Any applicant for a land use change or development permit requiring approval of the City
Commission, or any person/entity seeking a City contract through a request for proposal, request
for qualification, or sealed bid process (all referred to as applicant):
A. Shall not induce, attempt to offer, solicit or knowing assist any person in violating the Ethics
Code.
B. All applicants shall include the following with their application, proposal, or bid:
(Attach additional sheets as needed for each item.)
1. A listing of all campaign contributions to sitting City Commissioners in the past four
(4) years, as well as contributions of all officers, directors, shareholders of a
corporation if the application is a corporation, or partners if the applicant is a
partnership, or members, whether general or limited, if it is a limited liability
company.
___________________________________________________________
___________________________________________________________
___________________________________________________________
2. Disclose all those items that a regulated officer is required to disclose concerning
any conflict, whether actionable or non-actionable.
___________________________________________________________
___________________________________________________________
___________________________________________________________
3. Disclose any action that is a violation of the Ethics Code by a regulated office (in
reference to the application) with the applicant and/or the applicant’s agents, and
what was done to rectify the violation (for example: if a gift was given, when
demand was made for return of the gift.)
___________________________________________________________
___________________________________________________________
___________________________________________________________
4. An applicant shall fully, completely, accurately, and not misleadingly report and file
all disclosures required by this Ethics Code, and shall fully, completely, accurately,
and not misleadingly make all disclosures referenced in this Ethics Code and not
omit material information, and/or file misleading and/or deceitful information in the
disclosure.
5. An applicant has a continuing duty to report any violation of this Ethics Code
related to their application.
6. Failure to disclose in compliance with this Section shall be a violation of this Ethics
Code and shall be grounds for the City Commission to void or rescind any approval
or contract.
C. No applicant shall, directly or indirectly, induce, encourage, or aid anyone to violate any
provision of this Code.
I, ____________________, have received a copy of the ordinance and understand the ordinance
requirements.
Applicant
_______________________ ________________
Signature Date
SWORN TO AND SUBSCRIBED Before me by means of physical presence or online
notarization, this_____________ day of _______________________________, 202__ by
____________________________________________________ (Affiant), who is personally
known to me or has produced ____________________________________ identification.
My commission expires: ___________________
Commission No.: _________________________
_________________________________________
(Signature of Notary Public - State of Florida)
_________________________________________
(Print, Type, or Stamp Commissioned Name of
Notary Public)
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Completed 2 April 2021

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