Attachment 4 - Conflict of Interest Statement.pdf

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Car Wash Rack System Cannon AFB
Solicitation number
FA485526Q0017
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This is a Conflict of Interest Statement form required for federal contract proposals under the Revolutionary FAR Overhaul (RFO) subpart 3.6.

The form mandates that respondents certify whether they or any company owners/controllers are Government employees as defined in 5 U.S.C. 2105. The Government is prohibited from awarding contracts to Government employees or organizations owned or substantially owned or controlled by Government employees. Respondents must select one of two certification options: either certify that neither they nor company ownership are Government employees, or disclose that they or company ownership are Government employees. The form additionally requires signatories to commit to disclosing any actual or potential conflicts of interest that arise during contract performance and to comply with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including RFO subparts 3.6 and 9.5 and any agency-specific requirements. The authorized company representative must sign the form under penalty of perjury, providing their name, organization, date, phone number, and email address.

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Other files

File Type Posted
Attachment 6 - Car Wash Pictures.pdf PDF
Attachment 7 - Answers From RFI.pdf PDF
Attachment 1 - Car Wash Rack Salient Characteristics.pdf PDF
Attachment 2 - Pricing Worksheet - Template for Commodities and One Time Services.xlsx XLSX spreadsheet
Combo - GOV Washrack - CO Signed.pdf PDF
Attachment 5 - FA485526Q0017 - Provisions and Clauses.pdf PDF
Attachment 3 - Offeror Information and Certification.pdf PDF

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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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