11-Form 2b - Conflict of Interest Certification UGE (DHHS26085).pdf
PDF 167 KB Posted
- Attached to
- Stabilization and Mobile Response
- Solicitation number
- DHHS26085
- Issued by
- Utah
About this file
This is a Governmental Entity Conflict of Interest Certification form issued by the State of Utah Department of Health and Human Services for entities entering into or applying for contracts with DHHS. The certification applies to the Stabilization and Mobile Response services contract in the Western Region, a five-year agreement with a service start date of September 18, 2026. The form requires the governmental entity to affirm that it is a political subdivision, agency, or municipality of Utah and that it has either entered into or applied for a contract with DHHS or has entered into a subcontract with a local agency holding a DHHS contract. The entity must maintain a written conflict of interest disclosure policy applicable to all representatives, including employees, owners, partners, directors, officers, board members, subcontractors, and agents with authority to establish policies or make decisions.
The certification obligates the governmental entity to monitor operations for compliance with DHHS conflict of interest provisions and to reasonably assure that representatives with potential conflicts of interest shall not make or influence decisions affecting the contract, monitor contract performance, or become involved in or benefit from contract performance. The form requires signatures and dates from authorized representatives of the governmental entity and must be completed and submitted as part of the contracting process. Volunteers are excluded from disclosure requirements unless they serve as board members, officers, or are substantially involved in the entity's decision-making processes.
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Text version
Gov’t Entity Conflict of Interest Certification Page 1 of 1 Revised 7/12/2023
State of Utah Department of Health and Human Services Governmental Entity Conflict of Interest Certification
Governmental Entity Name:
Address: City: State: Zip:
The governmental entity certifies that:
1. It is a political subdivision, agency, or municipality of the State of Utah;
2. It has either entered into, or applied for, a contract with the Department of Health and Human Services or one of the Department's divisions or offices ("DHHS") or it has entered into a subcontract with a local agency that has a contract with DHHS;
3. It maintains a written policy requiring its Representatives to disclose their conflicts of interest.
“Representative” means any person or entity acting on behalf of the contractor, and includes all employees, owners, partners, directors, officers, board members, subcontractors, and agents, as well as any individuals with authority to establish policies or make decisions for the contractor. Volunteers are not Representatives and are not required to be included in the contractor’s disclosure statement, unless they are board members or officers, or are substantially involved in the contractor's decision-making processes.
4. It will monitor its operations for compliance with the conflict of interest provisions in the DHHS contract, and it can reasonably assure DHHS that Representatives with a potential conflict of interest shall not:
a. make or influence decisions or set policies that affect the contract with DHHS or with a local agency;
b. monitor the performance of its contract with DHHS or with a local agency; or
c. become involved in or otherwise benefit from the performance of its contract with
DHHS or with a local agency.
Name: Date:
Title:
| Governmental Entity Name: |
| Address: |
| City: |
| State: |
| Zip: |
| Name: |
| Date: |
| Title: |
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