D4.pdf
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- Solicitation number
- 36C25625Q01572
About this file
This is a Conflict of Interest Statement form effective 02/01/2022 for Source Selection Evaluation Board (SSEB) members and advisors participating in a Department of Veterans Affairs procurement. The form requires SSEB participants to declare any potential conflicts of interest related to the acquisition being evaluated.
The form provides two certification options: 1) A declaration that neither the individual nor their immediate family has any financial interest in companies proposing on the acquisition, with a commitment to disclose if such interests arise, or 2) Disclosure of existing financial interests, relationships, or arrangements that could compromise independent judgment, including friendships, family/social relationships, employment connections, and housing/transportation arrangements. The form requires the participant's printed name, organization, phone number, signature, and date, with additional space on the reverse for detailed disclosures if needed.
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Other files
| File | Type | Posted |
|---|---|---|
| D1.pdf | ||
| D3.pdf | ||
| D2.pdf | ||
| 36C25625Q0157-2 0001.pdf | ||
| 36C25625Q0157-2.pdf | ||
| 36C25625Q0157-2_1.docx | DOCX document |
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Text version
Effective Date: 02/01/2022
Conflict of Interest Statement
______________________________________________SOURCE SELECTION
(Insert acquisition name)
Please review the list of prime contractors and their subcontractors who are offering proposals in response to the Request for Proposal (RFP) for the acquisition identified above with the Contracting Officer. After reviewing the list, check the appropriate boxes, fill in the information requested, and sign:
o I certify that neither I nor my immediate family, to the best of my knowledge, possess any financial interest whatsoever in any company, parent or subsidiary, which is proposing on the acquisition identified above now being considered by the Source Selection Evaluation Board (SSEB) of which I am a member or advisor. Should any company in which I or my immediate family has a financial interest submit a proposal to my source selection team, I will immediately reveal such interest to the SSEB Chairperson and the Contracting Officer.
OR
o I do possess a financial interest in a company that is proposing on or is in a way involved in the acquisition identified above now being considered by the Source Selection Evaluation Board (SSEB) of which I am a member or advisor. (If you have checked this box, please provide a description of your financial interests on the reverse side of this form.) I further acknowledge my obligation to disclose any friendships; family or social relationships; past, present, or planned employment relationships, or any other type of relationship, such as housing or transportation arrangements, which might be perceived as compromising my independent judgment in connection with this Source Selection. (Please make any disclosures on the reverse of this form).
Name (print):____________________________________________
Organization: Phone:_____________________________________
Signature:_______________________________________________
Date:___________________________________________________
File details come from the government source that posted it. Updated .