AM0003 Attachment 4 Organizational Conflict of Interest Form.docx

Organizational Conflict of Interest (OCI) Disclosure Form

1. Purpose This form is used to identify and disclose any actual, potential, or perceived organizational conflicts of interest related to the performance of work under a contract, agreement, or solicitation.

2. Organization Information

· Organization Name: ___________________________

· Address: ____________________________________

· Primary Contact Name & Title: __________________

· Phone: _______________ Email: ______________

3. Contract / Solicitation Information

· Solicitation / Contract Number: __________________

· Project / Program Name: _______________________

4. Disclosure of Interests Please indicate if your organization, its affiliates, or subcontractors:

· ☐ Has provided systems engineering, technical direction, or evaluation services for this requirement.

· ☐ Has access to non-public information that could provide an unfair competitive advantage.

· ☐ Has financial, contractual, or other relationships that could impair objectivity.

· ☐ Has any other situation that may be perceived as a conflict of interest.

If any box is checked, provide details below:

Description of Conflict or Potential Conflict:

5. Mitigation Plan (if applicable) Describe measures your organization will take to avoid, neutralize, or mitigate the conflict:

6. Certification I certify that the information provided is true, complete, and accurate to the best of my knowledge. I agree to promptly notify the contracting officer or designated authority if any changes occur.

Authorized Representative:

· Name: ___________________________

· Title: ____________________________

· Signature: ________________________

· Date: ____________________________