Attachment 3 Organizational Conflict of Interest.pdf
PDF 3 MB Posted
- Solicitation number
- 36C26322Q0622
About this file
This document contains a solicitation for emergency shelter and related services in Omaha, Nebraska to support the Veterans Health Administration's Health Care for Homeless Veterans program. The Department of Veterans Affairs, Veterans Health Administration, Network Contracting Office is seeking proposals to provide shelter and services starting August 1, 2022 through July 31, 2027. Offerors must be able to perform all requirements in Omaha, Nebraska as described in the performance work statement. The solicitation is open through June 30, 2022 and interested offerors must submit their proposal via email before the closing date. Offerors must be registered in the System for Award Management and Vendor Information Pages databases. The North American Industry Classification code is 624221 for temporary shelters with a small business size standard of $12 million. Questions regarding this solicitation should be directed to the named contracting officer by the specified date.
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Text version
SOLICITATION #:
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
] ____________________________________ represents that no individuals involved with the solicitation ________________________________ 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 3 Organizational Conflicts of Interest Contractor Certification
CONTRACTOR NAME:
ADDRESS:
| Text3: |
| Contractor Company: |
| Solicitation#: |
| Address: |
| No COI affirmation: Choice1 |
| Date7_af_date: |
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