Attachment 05- Conflict of Interest Policy and Disclosure Form.pdf

Conflict of Interest Policy and Disclosure Form

A conflict of interest exists when there is evidence of or the appearance that an employee’s or contractor’s personal interests have influenced or may influence Agency transactions or operations, or that these interests take precedence over the interests, goals, and/or mission of the Agency. A conflict of interest may relate to you, your spouse/partner, family member, business interests, and/or associates in areas such as:

you (or a party related to you) hold, directly or indirectly a position of financial interest in an outside concern from which USDA secure goods or services.

you (or a party related to you) render directive, managerial, or consultative service to, or am an employee of, any outside concern that does business with USDA.

you have accepted gifts or other benefits from any outside concern that does, or is seeking to do, business with USDA.

you have participated in management decisions concerning transactions that affect or benefit you, my family, or my personal financial interests at USDA

A party related to you has received or continues to receive services from USDA.

USDA is responsible for knowing what conflicts might exist and to manage, reduce, or eliminate those conflicts. The key to handling these potential conflicts is full disclosure of any potential conflict or the appearance of a conflict. It appropriate to disclose any family members that may be supported by, employed by, a vendor of, or business associate of USDA.

If you have questions as to whether a conflict of interest exists, we encourage you to discuss this with USDA’s Compliance Officer and/or disclose this information on the form.

I certify by signing below I acknowledge receipt of the Employee/Contractor Conflict of Interest Policy and that I have accurately completed this disclosure form to the best of my knowledge.

Please check the statement that pertain to your disclosure:

I hereby report that to the best of my knowledge, information and belief, no situation in which I am involved personally or professionally could be construed as a violation of the Employee/Contractor Conflict of Interest Policy, or as placing me in a position of having a conflict of interest with USDA.

I hereby disclose the following circumstances that may constitute a conflict of interest, as described in the Employee/Contractor Conflict of Interest Policy above (please document all situations below that are or may be considered a conflict of interest):

I understand that it is my responsibility to contact USDA’s Compliance Officer to complete a new Employee/Contractor Conflict of Interest and Disclosure form to notify USDA of any changes and/or additions that may occur throughout the year.

If I am a contractor, I certify that I have submitted this form to my employing company appropriate point of contact, as the company may be precluded from bidding on any resultant solicitation for which I actively participated in the development of the requirement performance work statement or statement of work.

Name (please print) Signature

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