15-USBE Contractor COI Form.pdf
PDF 104 KB Posted
- Attached to
- USBE - Early Warning System (REPOST)
- Solicitation number
- USBE-MI26028-RFP
- Issued by
- Salt Lake County, Salt Lake City, Utah
About this file
This document is a Contractor Conflict of Interest Disclosure Form from the Utah State Board of Education. The form is designed to disclose and document potential conflicts of interest between a contractor and state employees, specifically addressing situations where an officer or employee of the contractor may also be an officer or employee of the State of Utah. The form requires detailed representations about the individual's roles, ownership interests, and potential improper use of official position.
The disclosure form requires the contractor to specify the type of business entity, identify any individual who is both a contractor representative and a state employee, and make several key representations. These include confirming that the individual has not improperly disclosed protected information, has not furthered the contractor's economic interests through their official position, and has not secured special privileges. The form provides two options for ownership disclosure, allowing contractors to indicate whether the individual and their family members own or control 10% or less (Option 1) or more than 10% (Option 2) of the contractor's stock or ownership interest. The contractor must also confirm obtaining a written declaration from the individual that they have not engaged in prohibited conduct under Utah procurement regulations.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 12-Scope of Work (final).pdf | ||
| 3-PII+Questionnaire (1).xlsx | XLSX spreadsheet | |
| 7-Att. B - USBE IT Terms and Conditions.docx | DOCX document | |
| 13-SISList SY2025.xlsx | XLSX spreadsheet | |
| 14-Technical Evaluation Criteria (final).pdf | ||
| 6-Att. A - USBE Standard Cooperative TsCs for Goods and Services.docx | DOCX document | |
| 9-Evaluation Score Sheet (final).pdf | ||
| 10-Mandatory Minimum Requirements (final).pdf | ||
| 16-USBE210049MA.zip | ZIP file | |
| 2-GRAMA-business-confidentiality.pdf | ||
| 4-RFP Prerequisites Document.pdf | ||
| 5-53F-4-207.pdf | ||
| 1-Changing+Your+Time+Zone.pptx | PPTX presentation | |
| 11-Sample Performance Monitoring Plan.pdf | ||
| 8-Cost Proposal Form (final).xlsx | XLSX spreadsheet |
Show all 15
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
UTAH STATE BOARD OF EDUCATION
CONTRACTOR CONFLICT OF INTEREST DISCLOSURE FORM
The State of Utah Standard Terms and Conditions include the following provision:
“CONFLICT OF INTEREST: Contractor represents that none of its officers or employees are officers or employees of the State Entity or the State of Utah, unless disclosure has been made to the State Entity.”
If an officer or employee of Contractor is an officer or employee of the Utah State Board of Education or the State of Utah, Contractor is required to complete and sign this form, notwithstanding the absence of any actual or perceived conflict of interest.
1. Contractor, _________________________, is a _________________________ (partnership, corporation, limited liability company, etc.) authorized to do business in the State of Utah.
2. Contractor represents that _________________________ (“Individual”) is an officer, employee, member, partner, or shareholder of Contractor, holding the title(s) of _________________________.
3. Contractor represents that Individual is an officer or employee of the State of Utah, holding the title(s) of _________________________ (“Official Position”) within the following State agency, department, or entity:
4. Contractor represents that Contractor has not required or induced Individual to improperly disclose to Contractor controlled, private, or protected information gained by reason of Individual’s Official Position, and Contractor has not knowingly received or accessed controlled, private, or protected information gained by reason of Individual’s Official Position.
5. Contractor represents that Contractor’s economic interest has not been substantially furthered by Individual’s use or attempt to use Individual’s Official Position.
6. Contractor represents that Contractor has not secured special privileges or exemptions by Individual’s use or attempt to use Individual’s Official Position.
7. Contractor represents that, combined, Individual and Individual’s family members, including Individual’s father, mother, husband, wife, son, daughter, sister, brother, uncle, aunt, nephew, niece, first cousin, mother-in-law, father-in-law, brother-in-law, sister-in-law, son-in-law, or daughter-in-law:
☐ Option 1:
a. Own or control no greater than 10% of the Contractor’s stock; and
b. Hold or control, directly or indirectly, an ownership interest of no greater than 10% of Contractor.
☐ Option 2:
a. Own or control greater than 10% of the Contractor’s stock, the amount of which is ______%; or
b. Hold or control, directly or indirectly, an ownership interest of greater than 10% of Contractor, the amount of which is ______%.
8. Contractor represents that Contractor has required and received a written declaration from Individual confirming Individual has not engaged in conduct prohibited by Utah Code § 67-16-4, Part 24 of the Utah Procurement Code, or associated administrative rules.
DATED this ____ day of __________________, 20___.
Signed
Name
Title
File details come from the government source that posted it. Updated .