Attachment 3 - Conflict of Interest Statement.pdf
PDF 186 KB Posted
- Attached to
- SERE Sun Shade (Canopy Replacement)
- Solicitation number
- FA485526Q0083
About this file
This is a Conflict of Interest Statement form template required for federal contract solicitations under the Revolutionary FAR Overhaul (RFO) subpart 3.6.
The form establishes that the Government prohibits contract awards to Government employees or organizations owned, substantially owned, or controlled by Government employees, as defined in 5 U.S.C. 2105. Respondents must certify via checkbox whether they or any company member with ownership or controlling interest is a Government employee. The form requires signatories to commit to disclosing any actual or potential conflicts of interest in writing to the Contracting Officer during contract performance and to cooperate with mitigation measures as needed. Signatories must also confirm compliance with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including RFO subparts 3.6 and 9.5, plus any agency-specific requirements. The form requires completion of signatory name, date, organization name, phone number, email address, and signature, with the signatory declaring under penalty of perjury that they have authority to legally bind the company and that all statements are true and correct to the best of their knowledge.
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Text version
ATTACHMENT 4 – CONFLICT OF INTEREST STATEMENT
Pursuant to the Revolutionary FAR Overhaul (RFO) subpart 3.6 – Contracts with Government Employees or Organizations Owned or Controlled by Them, the Government is prohibited from awarding a contract to a Government employee or other organization owned or substantially owned or controlled by one of more Government employees.
Employee means, an employee as defined in 5 U.S.C. 2105.
CONFLICT OF INTEREST STATEMENT
☐ I, the undersigned, certify that neither I nor any member of the company who owns or substantially owns or controls the company, to the best of my knowledge, is not an employee of the Government.
☐ I, the undersigned, certify that I or a member of the company who owns or substantially owns or controls the company, is an employee of the Government.
Disclosure of Potential Conflicts
If any actual or potential conflict of interest arises during the course of this engagement with the federal government, we will promptly disclose it in writing to the Contracting Officer and cooperate fully in any mitigation measures deemed necessary.
Commitment to Compliance
We understand and agree to comply with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including but not limited to RFO subpart 3.6 and RFO subpart
9.5 and any agency-specific requirements.
I, the undersigned, certify that I am an individual who has the authority to sign for and legally bind the Company and hereby declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.
Name: _______________________________________________ Date: _____________
Organization: __________________________________________________________________
Phone: __________________ Email: __________________________________________
Signature: _______________________________
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