4-Form 2b Conflict of Interest Certification UGE.pdf

167 KB Posted

Attached to
Outreach and Healthcare Access SUD
Solicitation number
DHHS91286
Issued by
Utah

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The document is a Governmental Entity Conflict of Interest Certification form from the State of Utah Department of Health and Human Services (DHHS). The form is designed for governmental entities that have either entered into or applied for a contract with DHHS or a local agency that has a contract with DHHS. The certification requires the governmental entity to confirm its status as a political subdivision, agency, or municipality of Utah and to acknowledge specific conflict of interest compliance requirements.

The certification mandates that the governmental entity maintain a written policy requiring its Representatives (defined as employees, owners, partners, directors, officers, subcontractors, agents, and individuals with policy-making authority) to disclose potential conflicts of interest. The entity must also commit to monitoring its operations to ensure that Representatives with potential conflicts do not make or influence decisions, monitor contract performance, or benefit from the contract with DHHS or a local agency. The form is to be signed and dated by an authorized representative of the governmental entity, formally attesting to their understanding and compliance with these conflict of interest provisions.

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Gov’t Entity Conflict of Interest Certification Page 1 of 1 Revised 7/12/2023

State of Utah Department of Health and Human Services Governmental Entity Conflict of Interest Certification

Governmental Entity Name:

Address: City: State: Zip:

The governmental entity certifies that:

1. It is a political subdivision, agency, or municipality of the State of Utah;

2. It has either entered into, or applied for, a contract with the Department of Health and Human Services or one of the Department's divisions or offices ("DHHS") or it has entered into a subcontract with a local agency that has a contract with DHHS;

3. It maintains a written policy requiring its Representatives to disclose their conflicts of interest.

“Representative” means any person or entity acting on behalf of the contractor, and includes all employees, owners, partners, directors, officers, board members, subcontractors, and agents, as well as any individuals with authority to establish policies or make decisions for the contractor. Volunteers are not Representatives and are not required to be included in the contractor’s disclosure statement, unless they are board members or officers, or are substantially involved in the contractor's decision-making processes.

4. It will monitor its operations for compliance with the conflict of interest provisions in the DHHS contract, and it can reasonably assure DHHS that Representatives with a potential conflict of interest shall not:

a. make or influence decisions or set policies that affect the contract with DHHS or with a local agency;

b. monitor the performance of its contract with DHHS or with a local agency; or

c. become involved in or otherwise benefit from the performance of its contract with

DHHS or with a local agency.

Name: Date:

Title:

Governmental Entity Name:
Address:
City:
State:
Zip:
Name:
Date:
Title:

File details come from the government source that posted it. Updated .