B08_R0004_Att_J-5_No_Conflict_of_Interest_Certificate.pdf

United States Department of the Interior

INTERIOR BUSINESS CENTER

Washington, DC 20240

ATTACHMENT J-5– CERTIFICATE OF NO CONFLICT OF INTEREST

CERTIFICATE OF NO CONFLICT OF INTEREST

for [Insert Award Number]

I certify that:

1. Except as set forth below, I do not presently hold, and will not obtain during my performance of services under this contract [Insert Award Number], any financial interest* or affiliation** in any non-

Federal entity impacted by my performance of such services.

2. To the best of my knowledge, and except as set forth below, my spouse and dependent children do not have a financial interest* or affiliation** in any non-Federal entity impacted by my performance of services under this contract.

3. To the best of my knowledge, and except as set forth below, none of the following is a non-Federal entity impacted by my performance of services under this contract, or represents a non-Federal entity impacted by my performance of such services.

· any person or company with whom I have or am seeking a business, contractual or other financial relationship that involves other than a routine consumer transaction;

· any close relative;

· any person or company with whom I have been affiliated within the last year;

· any organization in which I am an active participant.

4. I understand that I may request a statement from the Contracting Officer as to whether a particular person or particular company is considered to be impacted by my performance of services under this contract. I further understand that I have a continuing obligation, during the course of my performance of services under this contract, to update the information provided in paragraphs 1 through 3 of this certificate as needed.

*Financial Interest - Any continuing financial interest (such as through a pension or retirement plan, shared income, continuing termination payments, or other arrangements as a result of any current or prior employment or business or professional association) or any financial interest through legal or beneficial ownership of stock, stock options, bonds, securities, or other arrangements including trusts.

**Affiliation - A relationship as an employee, officer, owner, director, member, trustee, partner, advisor, agent, representative, or consultant; or a person having any understanding, plans or pending contacts regarding such a relationship in the future (this includes sending resumes, making telephone inquiries or any act that reasonably could be construed as an indication of interest in a future affiliation).

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