6-Form 2b Conflict of Interest Certification UGE.pdf
PDF 167 KB Posted
- Attached to
- Podiatry Services at Utah State Hosptial
- Solicitation number
- DHHS26156
- Issued by
- Utah
About this file
This is a Conflict of Interest Certification Form (Form 2b) for the University of Utah (UGE) related to the Podiatry Services contract at Utah State Hospital. The form serves as a formal declaration document for contractors or vendors to certify their compliance with conflict of interest regulations and policies applicable to state contracts in Utah. The certification requires authorized representatives to attest that they have reviewed applicable conflict of interest laws and regulations, understand their obligations, and confirm that neither they nor their organization has any undisclosed conflicts of interest that would impair their ability to perform the requested podiatry services at Utah State Hospital.
The form is a standard compliance instrument used by the state of Utah to ensure contractual integrity and proper governance. It typically requires the signature of an authorized representative, identification of the bidding entity, and acknowledgment of the certifier's authority to bind the organization to the representations made. This certification is a prerequisite for contract award and demonstrates the bidder's commitment to ethical business practices and regulatory compliance throughout the contract period for provision of podiatry services.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 2-DHHS BAA.pdf | ||
| 3-DHHS26256 SOW Podiatry Services at USH.docx | DOCX document | |
| 9-DHHS26256 Cost Proposal Form.doc | DOC document | |
| 4-DHHS26256 Podiatry IFB.docx | DOCX document | |
| 7-Form 2a Conflict of Interest Disclosure Statement.pdf | ||
| 5-Form 1 IRS Form W-9.pdf | ||
| 1-DHHS26256 Submission Instructions.docx | DOCX document | |
| 8-DHHS Client Service Terms.docx | DOCX document |
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Text version
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 .