ATTACHMENT 08 Conflicts of Interest Disclosures and Attestation.pdf

FORM 1: Conflicts of Interest Disclosures and Attestations HTA policies require the analysis and mitigation of Organizational Conflicts of Interest (OCI). The individual contractor’s reputation for integrity is a critical asset in performing government contract work. The Procurement Officer will use your answers to this questionnaire to identify and further evaluate the impacts of potential conflicts of interest and your proposed mitigation plans.

The form consists of two sections.

The first section asks yes/no questions designed to reveal any possible conflicts you may have.

If you answer “yes” to any of these questions you will need to provide an attachment with additional information, including persons or entities involved, the nature of the activity, and an estimate of the percentage of this contract that could be impacted by that activity, and any mitigation measures you have in place or plan to implement. Answering “yes” to any question will not automatically disqualify you. The explanations provided by you will allow HTA to evaluate the potential impacts of these conflicts and to analyze the respective mitigation plans.

The Procurement Manager may consider applicant’s candor, or lack thereof, in evaluating applicant’s responsiveness and responsibility. Omission or misrepresentation may be grounds for disqualification.

The second section is a list of affirmative statements that an authorized signer must initial agreement to. An authorized signer is someone who is authorized to legally and financially bind the company.

The first person "you," and the third person “we” and “our,” as used below, represent the individuals and organizations making a proposal under this RFP. The term "your associates" as used below includes any members of your board of directors, association members, partners, officers, employees, volunteers, agents, consultants, subcontractors, clients, customers or other associates who may benefit from or be involved in the performance of this contract.

Yes No QUESTIONS. (If answered “yes,” explanation must be attached.)

1. Tourism Industry Members. Not Applicable.

2. Destination Specific. Not Applicable.

3. Other Relationships. Do you or your associates have any existing or planned relationships (direct or indirect, including financial, organizational, contractual or otherwise) with any entity other than HTA that could affect in any way your performance under this contract?

4. Competing Markets. Not Applicable.

ATTACHMENT 08

5. State Contracts. Do you or your associates 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 HTA or any other Hawai'i state or local government or agency which are in any way related this solicitation?

6. Restrictions. Do you or your associates have any contracts, agreements, special clauses, legal prohibitions or other arrangements that may restrict your effort or independent judgment in proposing or performing any part of the work that you may need to perform under this solicitation?

7. Other Conflicts. Are you aware of any other potential conflicts of interest not described above?

8. Mitigation Plans. To avoid what you perceive as a possible organizational conflict of interest, do you propose to: exclude associates from portions of the proposed work; employ any special contract clauses; or take other measures? Please provide details.

ATTESTATIONS Initial of Authorized Signer

10. Self-Dealing. We will not engage in self-dealing, meaning that no work or effort performed under this contract will be used for our own benefit or to provide special access or benefits to our associates.

11. Access to Information. We will not utilize non-public information acquired in the performance of the proposed work—such as data generated under the contract, information concerning HTA plans and programs, or the confidential and proprietary data of others—for non-HTA activities,

12. Biased Ground Rules. We were not involved in preparing the requirements, developing the specifications, or drafting the statement of work for this solicitation.

13. Proposal Accuracy. We acknowledge and certify that the information contained in this proposal and application is true and correct to the best of our knowledge and has been duly authorized by the governing body of the organization.

14. General Conditions as Amended. We accept the State’s General Conditions (see APPENDIX 1, Attachment 1: HTA Website References – Hawai‘i State General Conditions) as amended in this RFP by the HTA, without exception.

15. Financial Resources. Not Applicable.

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

CONTRACTOR:

(Signature) (Date)

(Print Name and Title)

(Company)

Number of Pages attached: