Attachment 4 - Conflict of Interest Statement.pdf
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- Attached to
- 27 SOSS Network Analyzers
- Solicitation number
- FA485526Q0051
About this file
This is a Conflict of Interest Statement template required for federal contract solicitations under the Revolutionary FAR Overhaul (RFO) subpart 3.6.
The document establishes that the Government is prohibited from awarding contracts to Government employees or organizations owned, substantially owned, or controlled by Government employees, as defined in 5 U.S.C. 2105. Offerors must certify under penalty of perjury whether they or any company owner, substantial owner, or controlling member is a Government employee. The statement includes two checkbox options: one certifying no Government employee affiliation and another certifying Government employee affiliation exists. Signatories commit to promptly disclosing any actual or potential conflicts of interest in writing to the Contracting Officer and cooperating with mitigation measures. All respondents must comply with applicable federal ethics, procurement integrity, and conflict of interest regulations, including RFO subpart 3.6 and RFO subpart 9.5, plus any agency-specific requirements. The form requires signature from an individual with authority to legally bind the company, along with name, date, organization, phone number, and email address.
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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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