5-DHHS25038 Attachment C (a) Conflict of Interest Form.pdf

This is a Conflict of Interest Form (Attachment C) for the Utah Department of Human Services (DHHS) related to a contract opportunity for audiology services at Utah State Correctional Facility (USCF) and Central Utah Correctional Facility (CUCF). The form requires bidders and their representatives to disclose any potential conflicts of interest, including financial interests, relationships with other parties to the transaction, and significant connections that could affect their ability to exercise independent judgment. All representatives must complete and sign the disclosure statement, certifying the accuracy of their responses and acknowledging the penalties for false statements.

The form establishes mandatory disclosure requirements for all individuals involved in the bidding process, including employees, officers, board members, and substantial owners. Respondents must disclose conflicts involving family members, business partners, and other entities with financial or ownership interests. Volunteers and non-representatives are explicitly excluded from the requirement unless they hold substantial involvement in the transaction. False or incomplete disclosures carry legal consequences, and the form warns that misrepresentation may result in bid disqualification or contract termination. The document includes specific instructions for identifying conflicts and requires notarization or certification of all statements submitted.