7-Conflict of Interest Certification Fillable Atty Approved 2026.pdf

Town of Ellington | Conflict of Interest Disclosure and Certification

TOWN OF ELLINGTON

CONNECTICUT • PROCUREMENT

Conflict of Interest Disclosure and Certification Complete this form and submit it with the bid or proposal response.

Bid or Proposal Title

Bid or Proposal Number

Vendor or Bidder Name

Date

Instructions Review each section, check the applicable box, provide details where requested, and sign the certification. If additional space is needed, attach a separate page and identify the applicable section.

1 Relationship Disclosure

Does the vendor, or any owner, officer, director, employee, subcontractor, consultant, or immediate family member, have any financial interest, personal relationship, employment relationship, or other affiliation that could create an actual or perceived conflict of interest involving this procurement or the resulting contract?

☐ Yes ☐ No

If Yes, explain the relationship and identify the individuals involved.

2 Town Official or Employee Disclosure

Check one option.

☐ An owner, officer, partner, director, employee, or principal of the vendor is an elected Town official.

☐ An owner, officer, partner, director, employee, or principal of the vendor is an appointed Town official.

☐ An owner, officer, partner, director, employee, or principal of the vendor is a Town employee.

☐ None of the above applies.

If one of the first three options is checked, complete the information below.

Name

Town Position or Office

Relationship to Vendor

Town of Ellington | Conflict of Interest Disclosure and Certification

TOWN OF ELLINGTON

CONNECTICUT • PROCUREMENT

3 Additional Disclosures

List any current or pending contracts, consulting agreements, business relationships, or other arrangements with the Town that may be relevant to this procurement. If none, write “None.”

4 Certification

I certify that the information in this Conflict of Interest Disclosure and Certification is true, accurate, and complete to the best of my knowledge. I understand that failure to disclose a conflict of interest, or providing false or misleading information, may result in disqualification from the procurement process, termination of any resulting contract, or other remedies permitted by law.

I agree to promptly notify the Town in writing if an actual or potential conflict of interest arises during the procurement process or the term of any resulting contract.

False Statement Acknowledgment The undersigned bidder acknowledges that this statement is made under penalty of false statement pursuant to Connecticut General Statutes § 53a-157b.

Authorized Signature

Printed Name

Title

Date

Reference Provisions

Town Charter Section 1303 Conflict of Interest Any elected or appointed officer, member of a board or commission, or Town employee who has a direct or indirect financial interest in a contract, transaction, or decision must disclose that interest to the Board of Selectmen for the official record and is disqualified from participating in the award, assignment, or discussion. Violation may be grounds for removal.

Personnel Rules Section 220-10.4 Conflict of Interest An appointed or elected Town officer or employee who has or may have a significant direct or indirect financial interest in a Town contract, transaction, or decision must immediately disclose the nature and extent of that interest in writing to the Town Clerk. The disclosure is recorded and distributed as provided in the Personnel Rules.