D.7_-_OCI_Questionnaire_(blank).pdf

Attachment 1

Name of Person or Organization:

OCI Questionnaire1

1. Will you (or your organization) be involved, or have you previously been involved, in the performance of any portion of the project under this solicitation, aside from your organization’s proposed work as a third-party contractor?

( ) No.

( ) Yes. The portion of the proposed work; the proposed hours and dollar value; and the type of involvement are fully disclosed on the attached pages.

2. What is (are) the major type(s) of business conducted by you (or your organization)? Please reply on the attached pages.

3. Do you (or your organization) have any affiliates?

( ) No.

( ) Yes. The name and a description of the major type(s) of business that each affiliate conducts are disclosed on the attached pages.

4. Will any of the following be involved in performing the proposed work under this solicitation: (a) any entities owned or represented by you (or your organization);

(b) your organization’s Chief Executive or any of its directors; or (c) any affiliates?2

( ) No.

( ) Yes. A full disclosure and discussion is given in the attached pages.

1 All questions in the questionnaire apply to parent companies and affiliates as well. Whenever possible, each affiliate should submit a separate questionnaire. However, in the event each affiliate does not submit a separate questionnaire (for instance, to avoid completing a large number of questionnaires), this questionnaire must incorporate information regarding all affiliates.

2 See Definitions in Chapter 4 (defining affiliates as businesses that directly or indirectly control or have the power to control another, or when a single third party controls or has the power to control both businesses).

5. Are you (or your organization) an energy concern?

( ) Yes. A full disclosure and discussion is given on the attached pages.

6. Do you (or your organization) have a direct or indirect relationship (financial, organizational, contractual or otherwise) with any business entity (including a parent company, affiliate, or any other business arrangement) that could be affected in any way by the proposed work under this solicitation?

( ) No.

( ) Yes. List the business entity(ies) showing the nature of your relationship

(including the dates of the relationship, and the dollar value of any financial relationship) and how it would be affected by the proposed work under this solicitation.

7. What percentage of your total income for the current and preceding calendar years resulted from arrangements with any of the entities identified in Question 6 above?

% For the current calendar year: from / / to / / .

% For the preceding calendar year: from / / to / / .

% For the second preceding calendar year: from / / to / / .

8. Do you (or your organization) currently have or have you had during the last six years any arrangements (for example, contracts and cooperative agreements) awarded, administered, or funded—wholly or partly—by the Commission or any other federal agency which relates to the proposed Statement of Work?

9. Do you (or your organization) have or have you ever had any contracts, agreements, special clauses, or other arrangements which prohibit you (or your organization) from proposing work to be performed in this solicitation or any portion thereof?

10. Do you (or your organization) have any involvement with or interest (direct or indirect) in technologies which are or may be subjects of the contract, or which may be substitutable for such technologies?

11. Could you (or your organization) in either your private or federal government business pursuits use information acquired in the performance of the proposed work under this solicitation; such as:

(a) Data generated under the contract?

(b) Information concerning Commission plans and programs?

(c) Confidential and proprietary data of others?

12. Under the proposed work under this solicitation, will you (or your organization) evaluate or inspect your own services or products, or the services or products of any other entity that has a relationship (organizational, financial, or other, such as a client) with you (or your organization)? This could include evaluating or inspecting a competitor’s goods and services.

13. To avoid what you perceive as a possible OCI, do you (or your organization) propose to: exclude portions of the proposed work; employ special clauses; or take other measures?

( ) No.

( ) Yes. A full discussion is given on the attached pages.

( ) No possibility of an OCI is perceived. This answer is briefly justified on the attached pages.

14. What percentage of the revenue reported in this OCI statement is attributable to work as a FERC third-party contractor?

15. Are you (or your organization) performing any function for another company, either currently or in the past 24 months, on a similar project in the same geographic area?

( ) Yes.

16. If the answer is yes, please list the name(s) of the project(s) and the work being performed.

I hereby certify that I have authority to represent my organization, and that, to the best of my knowledge and belief, the facts and representations presented on the four pages of this questionnaire and on the pages of the attachment to it are accurate and complete.

I recognize that OCI is an ongoing obligation requiring annual updating. Should I become aware of any actual or potential OCI during performance of this contract, I will advise the OEP staff and (applicant name) and file an amended OCI Statement with the Commission’s General and Administrative Law section, Office of General Counsel within 30 days that includes proposed mitigation or explanation why none is needed.

Signature : Date :

Name : Title :

Organization :