Attach L-03 - OCI Disclosure Form v2.0 (Extended).pdf

H95001-15-R-0001 Attachment L-03

OCI ANALYSIS/DISCLOSURE FORM v2.0 Integrated Research & Development for Enterprise Solutions (IRES) Contract

Part 1: Contractor Data

1. Contractor Name

2. CAGE Code

3. Point of Contact

4. IRES Prime or Sub

5. Type of work to be performed on IRES

6. Affiliates

Part 2: Contractor’s Other MDA- or BMD-related Work

7. Prime Contract Number

8. Prime Contract Title

9. Gov’t Contracting Officer

10. Period of Performance

11. Prime or Sub and

Description of Work Performed

12. Relationship to or interaction with the work identified in Block 5

Part 3: Contractor’s OCI Analysis

13. Does Actual OCI exist? Yes No

14. Does Potential OCI exist? Yes No

15. Summary of actual / potential OCI or why there is no potential OCI

Part 4: Name of Responsible Company Official

16. Typed Name and Title

17. Contact Information

18. Date

H95001-15-R-0001 Attachment L-03

INSTRUCTIONS FOR COMPLETING OCI ANALYSIS/DISCLOSURE FORM

Responses to any items may reference attached documents as necessary.

Part 1: Contractor Data

Blocks 1and 2: Enter Contractor name and CAGE code. The “contractor” for purposes of this form could be the offeror, subcontractor, or affiliate of either

Block 3: Enter the name, telephone number, and email address of the contractor point of contact that is most knowledgeable of both the IRES work to be performed in Part 1 as well as the work performed under the contract identified in Part 2.

Blocks 4 and 5 Identify whether the Contractor identified in Block 1 is a prime or subcontractor on IRES. Describe the work to be performed on the IRES contract, including the primary IRES high level objective(s) (HLOs).

Block 6: Provide a list of all affiliates of the contractor named in Block 1.

Part 2: Contractor’s Other MDA- or BMDS-related Work

Block 7: Enter the MDA or BMDS-related prime contract number and task order number and subcontract number (if applicable).

Block 8: Enter the prime contract or task order title.

Block 9: Enter the name, telephone number, and email address of the prime contract’s

Government Contracting Officer.

Block 10: Enter the period of performance of the contract or subcontract.

Block 11: Specify if the Contractor is the prime or subcontractor with regard to Block 7.

Provide a brief, but specific, narrative summary of the work performed on the contract. Specify if the work includes: providing systems engineering and technical direction, preparing specifications or work statements, providing evaluation services, obtaining access to proprietary information, or providing systems engineering and technical assistance, as defined in FAR 9.5 and DFARS 209.5.

Block 12: Enter a brief, but specific, narrative summary of any known or anticipated relationship or interaction between this contract and the IRES contract or the Joint National Integration Research and Development Contract (JRDC); if none, so state.

Identify all non-public IRES acquisition information accessed or obtained. Be as specific as possible in terms of describing what information/documents were accessed and for what purpose you had access; if none, so state.

Part 3: Contractor’s OCI Analysis Blocks 13 and 14: Place an "X" in the appropriate response (yes or no).

Block 15: Enter a summary of the actual or potential OCI, considering the following types:

(a) impaired objectivity, (2) biased ground rules, (3) unequal access to information;

and (4) Systems Engineering and Technical Assistance (SETA) (reference L.6.3.4).

Provide any current OCI restrictions, mitigation plans, or OCI advisory letters involving this contract that may impact IRES. Describe the actions planned to avoid, neutralize, or mitigate actual or potential OCI identified. If no potential OCI exists, briefly summarize why.

Part 4: Name of Responsible Company Official Blocks 16 – 18: Provide the name, title, and contact information of the company official with responsibility for and/or authority to discuss and commit the company on matters relating to OCI issues. Please also provide the date the form was completed.