Attachment 4 - Conflict of Interest Statement (1).pdf
PDF 186 KB Posted
- Attached to
- Melrose Air Force Range Caliche
- Solicitation number
- FA485526Q0009
About this file
This is a Conflict of Interest Statement template required as an attachment to a federal contract solicitation under the Revolutionary FAR Overhaul (RFO) subpart 3.6. The document establishes compliance requirements prohibiting the Government from awarding contracts to Government employees or organizations owned, substantially owned, or controlled by one or more Government employees, with "employee" defined according to 5 U.S.C. 2105.
The statement requires the signatory to certify under penalty of perjury whether they or any company owner/controller is a Government employee, with two checkbox options provided for affirmative or negative disclosure. The document obligates contractors to promptly disclose any actual or potential conflicts of interest in writing to the Contracting Officer and cooperate with mitigation measures. Signatories must commit to compliance with all applicable federal ethics, procurement integrity, and conflict of interest regulations under RFO subpart 3.6 and RFO subpart 9.5, plus any agency-specific requirements. The template requires completion of name, date, organization, phone, email, and signature fields by an individual authorized to legally bind the company. This is a template document without specific solicitation details, products, services, or award information.
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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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