35789_Att C.1_Conflict Of Interest Disclosure Form.docx

CONFLICT OF INTEREST (COI) DISCLOSURE FORM

Oregon Department of Transportation Firms under Contract or proposing to enter into a Contract with Agency must be in conformance with the ODOT Conflict of Interest Guidelines for Procurements & Contracts (“COI Guidelines”). The definitions of terms used in this COI Disclosure Form shall be those provided in the COI Guidelines (note that “Public Official” includes all Agency employees).

This COI Disclosure Form is submitted in response to (check only one):

|_| Agency RFP# [or] ITB# |_| Contract # |_| Price Agreement # WOC# [or] PO# |_| Changes to COI Disclosure Form previously submitted for (RFP # , ITB # , Price Agreement # , WOC # , Contract # This COI Disclosure Form must be signed in ink by a principal of the Firm to certify that it is correct. A Firm’s certification that its disclosure form is correct includes the disclosure by its Associates and Subcontractors.

My signature certifies that as disclosed on or attached to the present form:

(a) the Firm’s disclosures are complete, accurate, and not misleading.

(b) the Firm has provided the ODOT COI Guidelines to all Associates and Subcontractors (if any) and the present form includes or has attached any required COI disclosures from those sources.

I hereby certify that I am authorized to sign this COI Disclosure Form as a Representative for the Firm identified below:

Complete Legal Name of Firm:

Address:

Telephone: ; Fax No:

Authorized Representative’s Name (printed):

Signature: _________________________________________________________ Date:

Please answer all questions “Yes”, “No” or “N/A” (if uncertain answer “Yes”).If the answer to any of the questions is “Yes,” then use the applicable “Comments” fields to:

(a) furnish all relevant facts that are necessary to make the response complete, accurate, and not misleading; and

(b) identify any actions that must be taken to avoid, neutralize, or mitigate such conflict of interest (e.g. communications barriers, restraint or restriction upon future contracting activities, or other precaution)

1. a) Is any Associate of the Firm a former employee of Agency within the last two years that had or will have involvement (on Agency’s or Firm’s behalf) with this Procurement, Contract, subcontract, or the prospective Project?

No |_|, Yes |_|

b) Is any Associate of the Firm a Relative or Member of the Household of a current Agency employee that had or will have any involvement with this Procurement or Contract Authorization?

No |_|, Yes |_| If the answer to either of the above questions is “Yes”, complete the attached “Relatives and Former Agency Employees” table (Part A and/or Part B, as applicable).

2. 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 Agency evaluation or selection team for the Procurement?

No |_|, Yes |_|, Comments:

3. Did the Firm or any Associate of the Firm conduct prior work on the Project described in the Procurement, or participate in preparing any part of the Procurement or any documents or reports related to the Procurement or to which the Procurement refers?

No |_|, Yes |_|, Comments:

4. Does the Firm or any Associate of the Firm have any past, present or currently planned personal or financial interests which are an Actual, Apparent or Potential Conflict of Interest (“Individual” or “Organizational”), with respect to the Procurement or award of this Contract or performing the work for Agency or acquisition of any real property for the Project?

No |_|, Yes |_|, Comments:

5. Has the Firm or an Associate of the Firm offered to a Public Official, or is the Firm aware of any Public Official that has solicited or received, directly or indirectly, any pledge or promise of employment or other benefit based on the understanding that the Public Official’s vote, official action or judgment would be influenced thereby?

No |_|, Yes |_|, Comments:

6. Has (or will) the Firm or an Associate of the Firm provided a direct beneficial financial interest to any person within two years after the person ceased to hold a position as a Public Official who was involved in the Procurement or Authorization for the Contract, or is the Firm aware of any such person or Public Official who has or will receive a direct beneficial financial interest within the two year period?

No |_|, Yes |_|, Comments:

7. Is the Firm aware of any current or former Public Official that has an Actual, Apparent or Potential Conflict Of Interest with respect to the Procurement or award of this Contract or performing the work for Agency?

No |_|, Yes |_|, Comments:

8. Does the prospective Contract/WOC include development of an Environmental Assessment (EA) or Environmental Impact Statement (EIS)?

No |_|, Yes |_|, Comments:

If yes, in accordance with the disclosure statement requirements of Council on Environmental Quality Regulation, 40 C.F.R 1506.5(b)(4), does the Firm have any financial or other interest in the outcome of this Project; and/or does the Firm have any agreement, enforceable promise, or guarantee to provide any future work on this Project?

No |_|, Yes |_|, Comments:

9. Have Subcontractors or other Associates furnished COI Disclosure Forms, separate from the present form, which included conflicts or potential conflicts of interest? (If yes, attach the disclosures.)

No |_|, Yes |_|, N/A|_|, Comments:

10. If the prospective Contract/WOC includes personal services for the purpose of administering, managing, monitoring, inspecting, evaluating compliance with or otherwise overseeing a public contract, is the Firm or an Associate or an Affiliate of the Firm a party to the subject public contract?

No |_|, Yes |_|, N/A|_|, Comments:

11. Has the Firm or any Associate of the Firm entered into personal services contract(s) with Agency for the purpose of advising or assisting in developing specifications, a scope or statement of work, an invitation to bid, a request for proposals or other solicitation documents and materials related to this procurement?

No |_|, Yes |_|, Comments:

12. If the prospective Contract/WOC includes, or is advertised to potentially include via later amendment, personal services related to Project construction, do any of the criteria set forth in COI Guidelines, section (4) - “COI Considerations Related to Consultant Services Provided During Project Construction” apply?

No |_|, Yes |_|, N/A |_| If yes, provide comments to describe the potential conflict. Include or attach a mitigation plan if applicable (or if required) to address the criteria in section (4) of the COI Guidelines.

Comments:

Relatives and Former Agency Employees For each employee of the Firm that was employed by Agency within the last two years and that had or will have involvement (on Agency’s or Firm’s behalf) with this Procurement, Contract, subcontract, or the prospective Project, provide information in Part A below as applicable.

Use Part B for Firm Associates with Relatives or Members of the Household working for Agency that had or will have involvement with this Procurement or Contract.

Part A: Employees that left Agency in the last two years and that had or will have involvement with this Procurement, Contract, subcontract, or the prospective Project.

Instructions: If applicable, enter employee name(s) and the date(s) they left the Agency. For each employee identified, enter employee role information in Column C or D or both C and D, as applicable.

Column A Employee Name

Column B Date employee left Agency Column C Role performed on behalf of Agency related to this procurement or prospective Project Column D Proposed Role on behalf of Firm in current Procurement, Contract, subcontract or Project

Part B: Identify Associates of the Firm that are Relatives or Members of the Household of Agency employees currently working for Agency, if the Agency employee had or will have any involvement with this Procurement or Contract.

Firm Associate’s Name

(Make copies of this form as needed to list additional employees.)

Level 3 - Restricted

Level 3 - Restricted

ODOT COI Form; 11/10/21Level 3 - Restricted