5-Appendix C Acknowledgement of Personnel Relationships.pdf

618 KB Posted

Attached to
Jefferson Academy- Food Service Management
Solicitation number
RA26-146
Issued by
Davis County, Utah

About this file

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This is an Acknowledgement of Personnel Relationships form for a Food Service Management Contract (FSMC) between Jefferson Academy (the School Food Authority or SFA) and a food service management company. The form documents instances where the same individual(s) are employed by both Jefferson Academy and the contracted food service management company, requiring certification that such employees do not present conflicts of interest. The document includes checkboxes to indicate whether shared employees exist and mandates that any such employees must not participate in contract selection, award, or administration; lack access to food service financial accounts or student information systems; be excluded from pricing decisions for meals and food items; and have no involvement in free and reduced-price meal eligibility determinations or verification processes. The form requires signatures from authorized representatives of both Jefferson Academy and the FSMC, with Nicole Jones identified as the Director representing Jefferson Academy.

The form indicates that Jefferson Academy has confirmed the existence of shared personnel between the SFA and FSMC through the affirmative checkbox selection. The acknowledgement serves as a compliance document within the broader Food Service Management solicitation for Jefferson Academy, located in Kaysville, Utah, with proposals due to Nicole Jones by June 29, 2026 at 3:00 PM MDT. Questions regarding the procurement opportunity may be submitted to njones@jeffersonacademy.org with a cutoff date of June 5, 2026 at 5:00 PM MDT. This form is part of Jefferson Academy's procurement documentation and does not constitute a commitment from the Utah Division of Purchasing.

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Appendix C

Acknowledgement of Personnel Relationships The SFA employs the same person/people that is/are employee(s) of the FSMC: (Check one)

☐ Yes ☐ No

If yes, we the undersigned certify that the employee(s):

• Does not have a real or apparent conflict of interest.

• Will not participate in the selection, award, or administration of the contract.

• Will not have access to or control of the food service financial account.

• Will not be involved in the establishment of the selling prices for all reimbursable and non-reimbursable meals, a la carte items, adult meals, catering, or vending items.

• Will not have access to SFA’s Student information software system or foodservice software system.

• Will not be involved in the completion, distribution or collection of the parent letters and household applications for free and reduced-price meals.

• Will not be involved in the determination or verification of eligibility for free and reduced-price meals.

Employee Name SFA Position Title and Job Duties FSMC Position Title and Job Duties

SFA FSMC

SFA Authorized Representative Signature FSMC Authorized Representative Signature

Printed Name of SFA Authorized Printed Name of FSMC Authorized

SFA Authorized Representative Title FSMC Authorized Representative Title

1 Revised: 04/24/2026

Employee NameRow1:
SFA Position Title and Job DutiesRow1:
FSMC Position Title and Job DutiesRow1:
Employee NameRow2:
SFA Position Title and Job DutiesRow2:
FSMC Position Title and Job DutiesRow2:
Employee NameRow3:
SFA Position Title and Job DutiesRow3:
FSMC Position Title and Job DutiesRow3:
Employee NameRow4:
SFA Position Title and Job DutiesRow4:
FSMC Position Title and Job DutiesRow4:
Employee NameRow5:
SFA Position Title and Job DutiesRow5:
FSMC Position Title and Job DutiesRow5:
Employee NameRow6:
SFA Position Title and Job DutiesRow6:
FSMC Position Title and Job DutiesRow6:
Employee NameRow7:
SFA Position Title and Job DutiesRow7:
FSMC Position Title and Job DutiesRow7:
Employee NameRow8:
SFA Position Title and Job DutiesRow8:
FSMC Position Title and Job DutiesRow8:
Employee NameRow9:
SFA Position Title and Job DutiesRow9:
FSMC Position Title and Job DutiesRow9:
Employee NameRow10:
SFA Position Title and Job DutiesRow10:
FSMC Position Title and Job DutiesRow10:
SFA: Jefferson Academy
FSMC:
Printed Name of SFA Authorized: Nicole Jones
Printed Name of FSMC Authorized:
SFA Authorized Representative Title: Director
FSMC Authorized Representative Title:
Signature1_es_:signer:signature:
Signature2_es_:signer:signature:
Check Box3: Off
Check Box4: Yes

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