2-Exhibit B - Conflict of Interest Disclosure.docx

DOCX document 32 KB Posted

Attached to
City of Herriman - Solicitation for Utility Billing Software
Solicitation number
HERR03272026
Issued by
Salt Lake County, Hildale City, Utah

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This is a Conflict of Interest Disclosure Form issued by the City of Herriman, Utah, as part of the Request for Proposal process for a Utility Billing Software implementation project. The form requires vendors and contractors to disclose any prior business relationships with City departments, including previous work performed or goods and services provided within the current or last fiscal year, along with corresponding amounts received. Additionally, vendors must disclose any grants or loans received from City departments within the same timeframe, including the grant or loan type, award date, and amount. The form mandates comprehensive disclosure of familial relationships between the business entity, its members, or immediate family members and any public officials or City employees, requiring the names, addresses, and departmental affiliations of such individuals.

The disclosure form further requires vendors to identify any paid consultants or lobbyists utilized in preparing the proposal submission and to describe in detail any direct benefits that would accrue to public officials or their family members as a result of contract award. By signing the form, vendors certify under oath and penalty of perjury that all statements are true and correct to the best of their knowledge, with the understanding that omissions or false statements shall result in disqualification from participation in the proposed transaction. This disclosure requirement is standard practice to ensure transparency and prevent conflicts of interest in the procurement process.

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Other files

File Type Posted
3-City of Herriman Utility Billing Software 4-3-2026 Revised.pdf PDF
2-Exhibit A - Reference Form.docx DOCX document
4-Attachment C - Functional Requirements.xlsx XLSX spreadsheet
1-RFP - Utility Billing Software.pdf PDF
3-Exhibit A - Reference Form.docx DOCX document
1-Exhibit B - Conflict of Interest Disclosure.docx DOCX document

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Attachment C – Conflict of Interest Disclosure

City of Herriman Vendor or Contractor Conflict of Interest Disclosure Form

Entity Completing Form:Click or tap here to enter text.

Address:Click or tap here to enter text.

City, State, ZIP:Click or tap here to enter text.

Phone Number:Click or tap here to enter text.

Contact Email Address:Click or tap here to enter text.

This form is provided with: Request for Proposal/Qualifications

1. Has your business entity or any of your business entities’ partners, divisions, or any related business entity previously performed work or provided goods or services to any City department within the current or last fiscal year?

Choose an item.

If yes, identify below the City department that received the goods and services, the type(s) of goods or services previously provided, and the amount received for the provision of goods or services (use additional pages if necessary)

City Department
Type of Goods/Services
Amount Received
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2. Has your business entity or any of your business entities’ partners, divisions, or any related business entity previously applied for and received any grants or loans from any City department within the current or last fiscal year?

Choose an item.

If yes, describe the type of grant or loan, the date such grant or loan was awarded, and the amount of the grant or loan.

Description of Grant or Loan
Date Grant Awarded
Amount of Grant or Loan
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3. List below the name(s) and address(es) of all public officials with whom your business entity, or members of your immediate family have a familial relationship. Identify the office the public official holds or the City department for which the public official works (attach additional sheets if necessary)

Name of Public Employee
Address
City Department
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4. List below the name(s) and addresses of all family members of public officials with whom your business entity, or members of your immediate family have a familial relationship. Identify the office the public official holds or the City department for which the public official works. Attach additional sheets if necessary).

Name of Family Member
Address
Name of Public Official/Employee Name
City Department Where Employed
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If you identified individuals in items one and/or two above, describe in detail below the direct benefit to be gained by the public officials, and/or their family members as a result of the contract, proposal, request for proposal, invitation to bid, or grant proposal. (Attach additional sheets if necessary.)

Click or tap here to enter text.

List below the name(s) and address(es) of all paid consultants and/or lobbyists utilized in preparation of this request for proposal or qualifications, invitation to bid, or grant or loan proposal:

Name of Paid Consultant/Lobbyist
Address
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By signing below, I certify under oath and penalty of perjury that all statements on or attached to this form are true and correct to the best of my knowledge. I further understand that omissions shall be cause for disqualification from participation on the proposed transaction.

Signature Date

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