Attachment_10_OCI_Statement.docx

Attachment #10

COMPLETE THE DISCLOSURE/REPRESENTATION STATEMENT

DESCRIBED BELOW

OCI DISCLOSURE/REPRESENTATION STATEMENT

(Check one of the following and sign below)

Statement of Work/Solicitation Number ________________________

No OCI, or potential OCI exists in relation to this contract.

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, all relevant facts concerning past, present or currently planned interests or activities (financial, contractual, organizational or otherwise) which relate to the proposed work and bear on whether I have (or the organization has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice, or (2) being given an unfair competitive advantage are fully disclosed on the attached page(s) and formatted to show:

· For ease of presentation, divide following data into four parts: Organizational, contractual, financial other;

· The company, agency, organization in which you have a past, present, or currently planned interest or activity (financial, contractual, organizational, or otherwise);

· A brief description of relationship (including scope of work);

· Period of relationship;

· The extent of relationship (e.g., value of financial interest of work; percent of total holdings, total work, etc.).

Signature:

Name:

Title:

Date:

Organization: