COI Doc.docx

FOR INTERNAL FEC USE ONLY

FEC Conflict of Interest (COI) Statement for FEC Employees

Title of Acquisition: ________________________________________________________ Please review the list of prime contractors and their subcontractors who are offering proposals in response to the Request for Proposal (RFP) for the acquisition identified above. This list can be obtained from the Office of the Chief Financial Officer (OCFO) Contracting Division.

After reviewing the list, check the appropriate boxes, fill in the information requested, and sign.

|_| I certify that neither I nor my immediate family, possess any financial interest whatsoever in any company, parent or subsidiary, which is proposing on the acquisition identified above now being considered by the Source Evaluation Team (SET) of which I am a member or advisor. Should any company in which I or my immediate family has a financial interest submit a proposal in response to the aforementioned acquisition, I will reveal immediately such interest to the SET Chairperson and the Contracting Officer for this acquisition. (Please note that ownership of a financial interest in a company described in this paragraph which interest is valued at less than $15,000 is not disqualifying and need not be reported on this form. The $15,000 value is additive among your spouse and minor children, if applicable.) No organization or entity in which I serve as an officer, director, trustee, general partner, or employee, nor any organization or entity with which I am negotiating for, or have an arrangement concerning, prospective employment, is proposing on the acquisition identified above now being considered by the SET of which I am a member or advisor.

OR

|_| I do possess a financial interest, serve as an officer, director, trustee, general partner, or employee, or have an arrangement concerning prospective employment in a company that is proposing on or is in some way involved in the acquisition identified above now being considered by the SET of which I am a member or advisor. (If you have checked this box, please provide a description of your financial interests or other involvement on the Source Selection NDA for FEC Employees.) I further acknowledge my obligation to disclose any friendships; family or social relationships; past, present, or planned employment relationships, or any other type of relationship, such as housing or transportation arrangements, which might be perceived as compromising my independent judgment in connection with this Source Selection.

Please make any disclosures on the Source Selection NDA for FEC Employees.

Full Name (print): ________________________________________ Title: __________________________________________________ Signature: ______________________________________________ Date: ____________

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