Attachment 2- Organizational Conflict of Interest.pdf

ORGANIZATIONAL CONFLICTS OF INTEREST (JAN 2008)

CONTRACTOR NAME:

ADDRESS:

SOLICITATION #

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] ____________________________________ represents that no individuals involved with the

CONTRACTOR NAME

solicitation [_______________________________] in have no present, or currently planned interest SOLICITATION # and SERVICE TYPE

(financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Black Hills VA Health Care System.

None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the Central Iowa Health Care System – Des Moines Veterans Administration under the referenced solicitation.

OR

[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation.

The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.

NAME OF CERTIFYING OFFICIAL

TITLE

SIGNATURE DATE

Attachment 2