4-USBE Contractor COI Form.pdf
PDF 104 KB Posted
- Solicitation number
- USBE-MI27022-RFP
- Issued by
- Salt Lake County, Salt Lake City, Utah
About this file
UTAH STATE BOARD OF EDUCATION CONTRACTOR CONFLICT OF INTEREST DISCLOSURE FORM
This is a Contractor Conflict of Interest Disclosure Form issued by the Utah State Board of Education (USBE) as part of the solicitation for USBE-MI27022-RFP, which seeks external, independent investigators to serve the Utah Professional Practices Advisory Committee (UPPAC) on a rotating or random basis for hearings. The form is required when any officer, employee, member, partner, or shareholder of the contracting entity holds a concurrent position with the Utah State Board of Education or the State of Utah. The contract resulting from this RFP will operate until June 30, 2027, with the potential for four additional one-year renewal options, though USBE reserves the right to terminate the contract at any time in accordance with its Standard Terms and Conditions.
The form requires contractor disclosure and representation regarding the absence of improper conduct related to the dual position, including declarations that no controlled or protected information has been improperly disclosed, that the contractor's economic interests have not been substantially furthered through the official position, and that no special privileges or exemptions have been secured. Contractors must also declare their ownership structure, selecting either Option 1 (individual and family members own or control no greater than 10% of the contractor's stock or ownership interest) or Option 2 (specifying the percentage if greater than 10%). Additionally, contractors must obtain and provide written declaration from the individual confirming compliance with Utah Code 67-16-4 and Part 24 of the Utah Procurement Code.
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Other files
| File | Type | Posted |
|---|---|---|
| 1-Changing+Your+Time+Zone.pptx | PPTX presentation | |
| 3-PII+Questionnaire (1).xlsx | XLSX spreadsheet | |
| 8-RFP Prerequisites Document.pdf | ||
| 2-GRAMA-business-confidentiality.pdf | ||
| 7-Evaluation Score Sheet (final).pdf | ||
| 6-Cost Proposal Form (final).xlsx | XLSX spreadsheet | |
| 5-Att. A - USBE Standard TsCs for Goods and Services (rev. 8-2026).docx | DOCX document | |
| 11-USBE-MI27022-RFP Award Justification Statement.pdf | ||
| 9-SCOPE OF WORK (final).pdf | ||
| 12-USBE-MI27022-RFP - Award Memo.pdf | ||
| 10-Technical Evaluation Criteria (final).pdf |
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Text version
UTAH STATE BOARD OF EDUCATION
CONTRACTOR CONFLICT OF INTEREST DISCLOSURE FORM
The State of Utah Standard Terms and Conditions include the following provision:
“CONFLICT OF INTEREST: Contractor represents that none of its officers or employees are officers or employees of the State Entity or the State of Utah, unless disclosure has been made to the State Entity.”
If an officer or employee of Contractor is an officer or employee of the Utah State Board of Education or the State of Utah, Contractor is required to complete and sign this form, notwithstanding the absence of any actual or perceived conflict of interest.
1. Contractor, _________________________, is a _________________________ (partnership, corporation, limited liability company, etc.) authorized to do business in the State of Utah.
2. Contractor represents that _________________________ (“Individual”) is an officer, employee, member, partner, or shareholder of Contractor, holding the title(s) of _________________________.
3. Contractor represents that Individual is an officer or employee of the State of Utah, holding the title(s) of _________________________ (“Official Position”) within the following State agency, department, or entity:
4. Contractor represents that Contractor has not required or induced Individual to improperly disclose to Contractor controlled, private, or protected information gained by reason of Individual’s Official Position, and Contractor has not knowingly received or accessed controlled, private, or protected information gained by reason of Individual’s Official Position.
5. Contractor represents that Contractor’s economic interest has not been substantially furthered by Individual’s use or attempt to use Individual’s Official Position.
6. Contractor represents that Contractor has not secured special privileges or exemptions by Individual’s use or attempt to use Individual’s Official Position.
7. Contractor represents that, combined, Individual and Individual’s family members, including Individual’s father, mother, husband, wife, son, daughter, sister, brother, uncle, aunt, nephew, niece, first cousin, mother-in-law, father-in-law, brother-in-law, sister-in-law, son-in-law, or daughter-in-law:
☐ Option 1:
a. Own or control no greater than 10% of the Contractor’s stock; and
b. Hold or control, directly or indirectly, an ownership interest of no greater than 10% of Contractor.
☐ Option 2:
a. Own or control greater than 10% of the Contractor’s stock, the amount of which is ______%; or
b. Hold or control, directly or indirectly, an ownership interest of greater than 10% of Contractor, the amount of which is ______%.
8. Contractor represents that Contractor has required and received a written declaration from Individual confirming Individual has not engaged in conduct prohibited by Utah Code § 67-16-4, Part 24 of the Utah Procurement Code, or associated administrative rules.
DATED this ____ day of __________________, 20___.
Signed
Name
Title
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