8-Form 2b Conflict of Interest Certification UGE.pdf
PDF 167 KB Posted
- Solicitation number
- DHHS26377
- Issued by
- Utah
About this file
This is a Governmental Entity Conflict of Interest Certification form issued by the State of Utah Department of Health and Human Services (DHHS) for entities entering into or applying for contracts related to the Projects for Assistance in Transition from Homelessness (PATH) grant program. The certification applies to political subdivisions, agencies, or municipalities of Utah that have either directly contracted with DHHS or its divisions, or have entered into subcontracts with local agencies holding DHHS contracts. The PATH program provides community-based outreach, mental health services, substance abuse treatment, case management, and other support services, as well as limited housing services for seriously mentally ill individuals experiencing homelessness.
The certification requires governmental entities to maintain a written conflict of interest policy applicable to all representatives, defined as any person or entity acting on behalf of the contractor, including employees, owners, partners, directors, officers, board members, subcontractors, and agents with decision-making authority. Entities must monitor operations for compliance and ensure that representatives with potential conflicts of interest do not make or influence decisions affecting the DHHS contract, monitor contract performance, or benefit from contract performance. Volunteers are exempt from disclosure requirements unless they serve as board members, officers, or are substantially involved in organizational decision-making processes. The certification requires signature and date confirmation from authorized representatives of the governmental entity.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 1-DHHS26377 PATH RFP Instructions and Checklist.docx | DOCX document | |
| 5-DHHS26377 PATH SOW OSUMH.docx | DOCX document | |
| 2-DHHS26377 Scoresheet PATH.xlsx | XLSX spreadsheet | |
| 4-DHHS26377 Budget Utilization Form.xlsx | XLSX spreadsheet | |
| 9-DHHS26377 RFP.docx | DOCX document | |
| 6-Form 2a Conflict of Interest Disclosure Statement.pdf | ||
| 7-DHHS Client Service Terms.docx | DOCX document | |
| 3-Form 1 IRS Form W-9.pdf |
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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 .