4-USBE Contractor COI Form.pdf
PDF 104 KB Posted
- Solicitation number
- USBE-MI27052-RFP
- Issued by
- Salt Lake County, Salt Lake City, Utah
About this file
This is a Contractor Conflict of Interest Disclosure Form issued by the Utah State Board of Education (USBE) for use in connection with the USBE Request for Proposals USBE-MI27052-RFP for Utah Professional Practices Advisory Committee (UPPAC) Investigators. The form serves to document and disclose any potential conflicts of interest when a contractor's officer, employee, member, partner, or shareholder holds a concurrent position within the State of Utah or USBE. Contractors must complete and submit this form if any such dual relationship exists, regardless of whether an actual conflict of interest is perceived. The form requires contractors to certify that they have not improperly induced state employees to disclose protected information, that economic interests have not been furthered through misuse of official positions, and that no special privileges or exemptions have been secured through such positions.
The form requires disclosure of ownership interests held by the contractor and related family members, with options to declare ownership of ten percent or less of contractor stock or to identify higher ownership percentages. Contractors must also confirm receipt of a written declaration from the relevant individual certifying compliance with Utah Code 67-16-4 and Part 24 of the Utah Procurement Code. The form requires execution with a signature, printed name, and title of an authorized representative, along with the date of execution. This disclosure mechanism ensures transparency and compliance with state procurement regulations governing potential conflicts of interest in contracting relationships with state entities.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 3-PII+Questionnaire (1).xlsx | XLSX spreadsheet | |
| 2-GRAMA-business-confidentiality.pdf | ||
| 5-Att. A - USBE Standard TsCs for Goods and Services (rev. 8-2026).docx | DOCX document | |
| 1-Changing+Your+Time+Zone.pptx | PPTX presentation | |
| 6-Evaluation Score Sheet.pdf | ||
| 8-SCOPE OF WORK.pdf | ||
| 9-RFP Prerequisites Document.pdf | ||
| 7-Technical Evaluation Criteria.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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
File details come from the government source that posted it. Updated .