Attachment 2 Organizational Conflict of Interest.pdf

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Attached to
Amended* 36C26326Q0007 0002 Iowa City CT Tech Services (SDVOSB set-aside)
Solicitation number
36C26326Q007
Issued by

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This document is a Contractor Conflict of Interest Certification Statement for Solicitation #36C26326Q0007, intended for the Central Iowa Health Care System – Des Moines Veterans Administration. The form provides two options for contractors to disclose potential conflicts of interest: either certifying that no individuals involved with the contract have present or planned conflicts of interest, or attaching a statement describing any past, present, or potential conflicts. The certification requires the contractor to declare any financial, contractual, organizational, or other interests that might compromise the objectivity of services to be provided, and mandates disclosure of conflicts for employees, consultants, and subcontractors identified in the proposal.

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Solicitation #:

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

] ____________________________________ represents that no individuals involved with the contract # ________________________________ in have no present, or currently planned 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.

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: Organizational Conflicts of Interest

Organizational Conflicts of Interest Contractor Certification

CONTRACTOR NAME:

ADDRESS:

Contract #:

Text3:
Contractor Company:
Address:
No COI affirmation: Choice1
Date7_af_date:
Contract #: (Contract # pending)
Solicitation #: 36C26326Q0007

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