0010_ANAD_OCI Disclosure Form.pdf

ORGANIZATIONAL CONFLICT OF INTEREST (OCI) DISCLOSURE FORM

Request for Project Proposal (RPP) Number: W91QEY-26-R-A002 Authority: 41 U.S.C. § 2303 note (Preventing Organizational Conflicts of Interest) and 41 U.S.C.

Chapter 21 (Procurement Integrity Act).

Reference: Tied to the Conflicts of Interest section in the Agreement Terms and Conditions

Company Name:

Participation Role:

Prime Offeror

Joint Venture (JV) Partner

Proposed Subcontractor

Point of Contact:

(Name & Title)

Email & Phone:

Check the appropriate box below (Select only one).

OPTION A: NEGATIVE RESPONSE (No Conflict) To the best of the Offeror's knowledge, no assistance, advice, proprietary data, or non-public information has been received by the Company, its principals, employees, proposed subcontractor companies, or Joint Venture partners from any:

1. Current or former federal employee (military or civilian), OR

2. Current or former government contractor who had access to non-public, proprietary, or non-public information regarding this effort.

OPTION B: NEGATIVE RESPONSE (Conflict Mitigated) Agreements Officer (AO) determined that the OCI has been mitigated. (See the attached AO signed OCI Mitigation Notification).

OPTION C: DISCLOSURE (Actual, Potential, or Apparent Conflict) The Offeror, its principals, employees, proposed subcontractor companies, or Joint Venture partners have received assistance, advice, proprietary data, or non-public information from a current/former federal employee or a government contractor regarding this effort.

*If Option C is checked, the Company must complete Section III on the following page.

Purpose: To maintain the integrity of the selection and award process, the U.S. Army requires all proposing Offerors to formally disclose any actual, potential, or apparent conflicts of interest. This includes the receipt of any assistance, advice, or non-public information from current/former federal employees or other government contractors.

SECTION I: COMPANY INFORMATION

SECTION II: DISCLOSURE INQUIRY & CERTIFICATION

06/04/2026

(Only required if you checked Option C in Section II. Duplicate this section if multiple individuals or entities are involved).

1. Source of Information / Assistance:

Current Federal Employee (Civilian/Military) Former Federal Employee (Civilian/Military) Current/Former Government Contractor Entity

2. Identifying Information:

Name of Individual or Contractor Entity:

Agency, Organization, or Company Name:

Last Known Title / Role:

3. Nature of Interaction & Information Provided:

Provide a detailed description of the assistance or non-public information received, including dates, the context of the interaction, and how it relates to RPP W91QEY-26-R-A002. Attach additional pages if necessary.

By signing below, I certify that I am an authorized representative of the Company listed above and that the information provided in this form is accurate, complete, and true to the best of my knowledge.

The Offeror acknowledges that compliance with this disclosure is a material requirement of the RPP. This completed form must be submitted as an attachment to the RPP package. Failure to provide this disclosure as an Attachment to the RPP, or providing false or misleading information, may result in disqualification from award consideration.

Authorized Offeror Representative Signature Date

Printed Name & Title

SECTION III: DETAILED DISCLOSURE DETAILS

SECTION IV: CERTIFICATION & SIGNATURE

06/04/2026