Attachment 3 - OCI Disclosure Statement.pdf

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APPENDIX A

COMPLETE EITHER THE REPRESENTATION OR THE DISCLOSURE –

NOT BOTH

OCI Representation Statement

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, no facts exist relevant to any past, present or currently planned interest or activity (financial, contractual, personal, organizational or otherwise) that relate to the proposed work; and bear on whether I have (or the organization and any of its affiliates has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice; or (2) being given an unfair1 competitive advantage.

Signature : Date :

Name : Title :

Organization :

OCI Disclosure Statement

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, all relevant facts -- concerning past, present, or currently planned interests or activities (financial, contractual, organizational or otherwise) that relate to the proposed work and bear on whether I have (or the organization has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice, or (2) being given an unfair competitive advantage—are fully disclosed on the following page(s) and formatted to show:

For ease of presentation, the OCI information is divided into four parts, indicating whether the possible OCI is: organizational, contractual, financial, or other;

The company, agency, organization in which I (or my organization) have a past, present, or currently planned interest or activity (financial, contractual, organizational, or otherwise);

1 An unfair competitive advantage does not include the normal flow of benefits from the performance of the contract.

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A brief description of the relationship;

The period of the relationship;

The extent of the relationship (such as value of financial interest of work;

percent of total holdings, total work, etc.); and A mitigation plan, if necessary.

Signature : Date :

Name : Title :

Organization :