36C24420Q0437-003.pdf

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

SECTION 1: CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[CONTRACTOR NAME]

[ADDRESS]

SOLICITATION #

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] ______________________________________________represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation for Mobile Lithotripsy Services, have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Lebanon Veterans Health Administration under the referenced solicitation.

None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___Lebanon VAMC_________ Veterans Administration under the referenced solicitation.

OR

[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.

NAME OF CERTIFYING OFFICIAL

TITLE

SIGNATURE DATE

SECTION 2: CONTRACTOR CERTIFICATION: IMMIGRATION AND NATIONALITY ACT OF 1952, AS

AMENDED

1. The Contractor must certify that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals;

a. Citizenship-related requirements. Each affected Contractor employee as described in paragraph shall be:

i. A United States (U.S.) citizen; or

ii. A national of the United States (see 8 U.S.C. 1408); or

iii. An alien lawfully admitted into the United States for permanent residence as evidenced by an Alien Registration Receipt Card Form I–151.

2. While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States.

3. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.

4. The Contractor must obtain a similar certification from its sub-contractors.

Signature: ____________________________________________

Date: ____________________________________________

Typed Name and Title: __________________________________________

Company Name: ___________________________________________

This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.

END OF SECTION D