Attachment 23 - Org Conflict of Interest.docx

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Q201--CBOC - Tupelo, MS - Amendment to Solicitation
Solicitation number
36C24920R0114
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This document contains a conflict of interest certification statement template for a federal contractor providing services to the Department of Veterans Affairs. The certification statement requires the contractor to disclose any past, present, or planned interests or conflicts of interest, financial, contractual, organizational, or otherwise, relating to the services to be provided under the solicitation. The contractor must also provide similar statements from any consultants or subcontractors involved in providing the services. The contractor may also provide details on how their organizational system would avoid or mitigate any actual or potential conflicts of interest.

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ATTACHMENT 23 – 36C249-20-R-0114

[CONTRACTOR NAME]

[ADDRESS]

SOLICITATION #VA249-17-R-0497

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation [____Solicitation # and Service Type___] 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 ___[NAME OF VAMC] _________ 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___NAME OF VAMC _________ 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

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