5-Supporting Documents 4 Conflict of Interest Disclosure Form.pdf

Chester City Hall, Municipal Building, 1 East 4th Street, Chester, Pennsylvania, 19013

Conflict of Interest Disclosure

Your company applied for a Contract or Program that may be part of one or more of the City of Chester’s (hereinafter the “City”) tax-funded projects or grant programs. Such projects and programs are subject to federal, state, or local laws prohibiting certain Conflicts of Interest, intended to assure the fair, equitable, and lawful use of public money. In awarding Grant funds or contracts for the sale or purchase of goods or services under a public bid or request for proposal, the City must request information to identify actual or potential conflicts. Under limited exceptions, the law may allow a waiver of a conflict. Bids and Proposals for Projects funded by taxes, including, but not limited to, any of the City’s General, Special Revenue, Capital Project, or Neighborhood Service Funds require conflict disclosures and are subject to the City’s procurement policies.

Programs, including, but not limited to, American Rescue Plan Act (ARPA), Community Development Block Grant (CDBG), or Emergency Solutions Grant (ESG), require conflict disclosures and are subject to separate rules and regulations prohibiting conflicts of interest. To identify actual or potential conflicts, the City requires Contract Vendors and Program Applicants to complete this Conflict-of-Interest Disclosure Form.

The purpose of this form is to identify potential vendors and applicants that may have a conflict under the rules and regulations. If the City determines a conflict exists, City staff will review the matter and, when authorized by law, process waiver requests under the requirements of a project or program. The City will make final Conflict of Interest determinations and process conflict waiver requests to federal or state agencies.

The Pennsylvania Ethics Act prohibits a public official or employee, or immediate family members (parent, spouse, sibling, or children) from benefiting, directly or indirectly, from a tax-funded contract or program. This includes any business or other entity where a public official, employee, or immediate family member may be employed, or hold any partial or full interest, or otherwise manage or control. Federal regulations prohibit any person responsible for deciding on any award of program funds from receiving program funds, directly or indirectly. This includes immediate family members and any business or other entity where a public official, employee, or immediate family member may be employed, or hold any partial or full interest, or otherwise manage or control. Under federal rules, immediate family includes a broad group of people and makes more entities subject to conflict rules, but also authorizes conflict waivers in limited circumstances. The rules vary by Program. Grant Applicants, bidders, and those responding to any type of request for proposal must fully complete and sign the attached Disclosure form.

Chester City Hall, Municipal Building, 1 East 4th Street, Chester, Pennsylvania, 19013

Conflict of Interest Disclosure

Please provide, in detail, any personal and/or business relationships the bidder and their immediate family members hold with any employees, officers, elected officials or Receiver of the City of Chester, PA.

If there are not any relationships, please initial at bottom or write “No existing business or personal relationships,” and complete the information at the bottom.

Please note that the existence of a relationship with a City of Chester employee, officer, elected official, or Receiver does not automatically disqualify your firm from providing services to the City of Chester.

__________ Initial here ONLY IF there are no existing personal and business relationships.

City of Chester Bid Number

City of Chester Project Name

Bidder Company Name

Bidder Company Contact Name

Signature

Title

Today’s Date

Email

Phone Number