5-USBE Contractor COI Form.pdf
PDF 104 KB Posted
- Attached to
- USBE Migrant Education Data System
- Solicitation number
- USBE-JB26296-RFP
- Issued by
- Utah
About this file
This is a Contractor Conflict of Interest Disclosure Form required by the Utah State Board of Education (USBE) for the Migrant Education Data System RFP (Solicitation #USBE-JB26296-RFP). The form must be completed by any contractor whose officers or employees are also officers or employees of the USBE or State of Utah. The contractor must disclose the individual's name, title, and position within the state agency or entity, and certify that no improper disclosure of controlled, private, or protected information has occurred and that the contractor's economic interests have not been furthered or granted special privileges through the individual's official position. The contract resulting from this RFP is anticipated to be a single award for five years with a maximum budget of $170,000, though USBE reserves the right to terminate at any time in accordance with state standard terms and conditions.
The form requires contractors to declare the ownership percentage held by the individual and their family members, choosing between two options: ownership or control of no greater than 10 percent of the contractor's stock and ownership interest, or ownership or control greater than 10 percent with the specific percentage disclosed. Additionally, the contractor must provide a written declaration from the individual confirming compliance with Utah Code 67-16-4 and Part 24 of the Utah Procurement Code. The form must be signed, dated, and submitted by the contractor's authorized representative, with the individual's name and title clearly identified.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 2-GRAMA-business-confidentiality.pdf | ||
| 9-Mandatory Minimum Requirements USBE-JB26296-RFP.pdf | ||
| 8-evaluation score sheet usbe-jb26296-rfp (2).xls | XLS spreadsheet | |
| 7-Cost Proposal Form USBE-JB26296-RFP.xlsx | XLSX spreadsheet | |
| 3-PII+Questionnaire (1).xlsx | XLSX spreadsheet | |
| 11-Technical Criteria USBE-JB26296-RFP.pdf | ||
| 4-Att. A - USBE Standard TsCs for Goods and Services (rev. 10-2025).pdf | ||
| 6-Attachment B Scope of Work USBE-JB26296-RFP.pdf | ||
| 10-RFP Prerequisites Document - USBE-JB26296-RFP.pdf | ||
| 1-Changing+Your+Time+Zone.pptx | PPTX presentation |
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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
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