3-08-Attachment-1 Potential-Conflict-of-Interest-Disclosure.pdf
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- Solicitation number
- Not on record
- Issued by
- Bucks County, Pennsylvania
About this file
This is a Potential Conflict of Interest Disclosure form related to the County of Bucks, Pennsylvania's procurement activities. The document pertains to multiple solicitations issued by the County across various service categories, including forensic crime lab operations, HVAC systems market research, behavioral health accounting and consulting services, commercial laundry equipment, janitorial supplies, trash compactor services, waterslide restoration, chiller replacement and installation, portable toilet services, and water proofing and drainage work. Contract terms vary by solicitation, with some unit cost contracts commencing April 1, 2026, for one to three-year periods with optional renewal extensions ranging from one to three additional years. Specific response deadlines and award dates are not uniformly detailed across all solicitations within this disclosure framework, though bidders are required to comply with submission timelines and, where applicable, pre-qualification requirements such as the County's Responsible Contractors Ordinance certification submitted at least 14 calendar days prior to bid submission.
The disclosure form addresses potential conflicts of interest that bidders and contractors must navigate when responding to County of Bucks solicitations. Certain solicitations, such as the chiller replacement project, mandate pre-qualification through the Contractor Responsibility Certification Form process. Bidders on portable toilet services must submit complete pricing for all specified locations to avoid non-responsive bid determinations. While specific pricing terms and set-aside provisions are not detailed within this conflict of interest disclosure document, the County's procurement framework typically incorporates standard government contracting practices regarding minority-owned, women-owned, and disadvantaged business enterprise considerations. Funding sources and budget allocations for individual projects are not specified in this disclosure document and would be detailed within respective bid packages and solicitation documents.
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POTENTIAL CONFLICT OF INTEREST DISCLOSURE FORM
Pursuant 2 CFR part 200, decisions concerning the federal grant funds must be free of undisclosed personal or organizational conflicts of interest, both in fact and in appearance. Conflict of interest provisions within the Code of Federal Regulations must be addressed as part of procurement and contracting processes. This Conflict of Interest (COI) Disclosure Form requires bidders (firm/vendor) to declare any personal, financial, or business affiliations that could present a conflict of interest or the appearance of one in relation to the contract or solicitation. If yes is answered to any of the below questions, please use the space to provide more information.
1. Does the Firm or any Associate of the Firm have an Actual, Apparent or Potential Conflict Of Interest (“Individual” or “Organizational”) with regard to any known member of the County’s procurement evaluation team, or any Elected Official, Officer, or Director?
☐ Yes: ____________________________________________________________________ ☐ No
2. Does any employee, officer, agent, or principal of the Firm (or any Associate/Subcontractor) have a family relationship with any employee, officer, or agent of the County that may influence, or appear to influence, impartial decision-making in this procurement?
☐ Yes: ____________________________________________________________________ ☐ No
3. Has any employee, officer, agent, or principal of the Firm (or any Associate/Subcontractor) offered or provided any gift, gratuity, favor, or anything of monetary value to any employee or official of the Agency in connection with this procurement?
☐ Yes: ____________________________________________________________________ ☐ No
4. Within the past 24 months, has the Firm or any Associate/Subcontractor participated in the development, drafting, or design of this solicitation (e.g., specifications, requirements, scope of work)?
☐ Yes: ____________________________________________________________________ ☐ No
5. Is any employee or principal of the Firm (or its Associates/Subcontractors) a former employee of the Agency who has left within the past 12 months?
☐ Yes: ____________________________________________________________________ ☐ No
6. Please use the space below to explain any other relationships, transactions, or circumstances not already disclosed that may present a conflict of interest or the appearance of a conflict related to this procurement.
This COI Disclosure Form must be signed in ink by a principal of the Firm to certify that it is correct.
My signature certifies that I am authorized to sign this COI Disclosure Form as a principal of the Firm and as disclosed on or attached to the present form:
(a) the Firm’s disclosures are complete, accurate, not misleading and do not omit any material information.
(b) the Firm has provided the COI Disclosure Form to all Associates and Subcontractors (if any) and the present form includes or has attached any required COI disclosures from those sources.
Legal Name of Firm: _______________________________________________________________
Address: _________________________________________________________________________
Telephone: ___________________
Signature: ________________________________________________________________________
Date: _______________________
| procurement evaluation team or any Elected Official Officer or Director: |
| Does any employee officer agent or principal of the Firm or any AssociateSubcontractor: Off |
| influence or appear to influence impartial decisionmaking in this procurement: |
| Has any employee officer agent or principal of the Firm or any AssociateSubcontractor: Off |
| or official of the Agency in connection with this procurement: |
| Within the past 24 months has the Firm or any AssociateSubcontractor participated in the: Off |
| of work: |
| Is any employee or principal of the Firm or its AssociatesSubcontractors a former: Off |
| employee of the Agency who has left within the past 12 months: |
| Please use the space below to explain any other relationships transactions or circumstances: Off |
| Legal Name of Firm: |
| Address: |
| Telephone: |
| Date: |
| Text1: |
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