6-Form 2b Conflict of Interest Certification UGE.pdf

167 KB Posted

Attached to
Community Based Peer Support Services
Solicitation number
DHHS26131
Issued by
Utah

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This is a Governmental Entity Conflict of Interest Certification form from the State of Utah Department of Health and Human Services (DHHS) related to Community Based Peer Support Services. The certification applies to political subdivisions, agencies, or municipalities of the State of Utah that have entered into or applied for contracts with DHHS or its divisions, or have entered into subcontracts with local agencies holding DHHS contracts. The form requires the governmental entity to certify that it maintains a written policy requiring all Representatives—defined as persons or entities acting on behalf of the contractor, including employees, owners, partners, directors, officers, board members, subcontractors, and agents with authority to establish policies or make decisions—to disclose conflicts of interest. Volunteers are excluded from disclosure requirements unless they serve as board members, officers, or are substantially involved in the contractor's decision-making processes.

The governmental entity must monitor its operations for compliance with conflict of interest provisions and provide reasonable assurance to DHHS that Representatives with potential conflicts of interest shall not make or influence decisions affecting the contract, monitor contract performance, or become involved in or benefit from contract performance. The form requires signatures and dates from authorized representatives of both the governmental entity and DHHS, with designated spaces for entity name, address, city, state, and zip code on the certification document.

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Gov’t Entity Conflict of Interest Certification Page 1 of 1 Revised 7/12/2023

State of Utah Department of Health and Human Services Governmental Entity Conflict of Interest Certification

Governmental Entity Name:

Address: City: State: Zip:

The governmental entity certifies that:

1. It is a political subdivision, agency, or municipality of the State of Utah;

2. It has either entered into, or applied for, a contract with the Department of Health and Human Services or one of the Department's divisions or offices ("DHHS") or it has entered into a subcontract with a local agency that has a contract with DHHS;

3. It maintains a written policy requiring its Representatives to disclose their conflicts of interest.

“Representative” means any person or entity acting on behalf of the contractor, and includes all employees, owners, partners, directors, officers, board members, subcontractors, and agents, as well as any individuals with authority to establish policies or make decisions for the contractor. Volunteers are not Representatives and are not required to be included in the contractor’s disclosure statement, unless they are board members or officers, or are substantially involved in the contractor's decision-making processes.

4. It will monitor its operations for compliance with the conflict of interest provisions in the DHHS contract, and it can reasonably assure DHHS that Representatives with a potential conflict of interest shall not:

a. make or influence decisions or set policies that affect the contract with DHHS or with a local agency;

b. monitor the performance of its contract with DHHS or with a local agency; or

c. become involved in or otherwise benefit from the performance of its contract with

DHHS or with a local agency.

Name: Date:

Title:

Governmental Entity Name:
Address:
City:
State:
Zip:
Name:
Date:
Title:

File details come from the government source that posted it. Updated .