Attachment 4 - Conflict of Interest Statement.pdf
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- Solicitation number
- FA485526Q0055
About this file
This is a Conflict of Interest Statement template required as part of a federal contract solicitation under the Revolutionary FAR Overhaul (RFO) subpart 3.6. The document establishes certification requirements for contractors regarding government employee affiliations and conflicts of interest.
The statement requires the signatory to certify whether they, or any member of the company with ownership or controlling interest, are employees of the federal government as defined in 5 U.S.C. 2105. The form includes two certification options: one confirming no government employee affiliation and another disclosing such affiliation. Additionally, the template mandates that contractors commit to disclosing any actual or potential conflicts of interest that arise during contract performance and agree to comply with all applicable federal ethics, procurement integrity, and conflict of interest regulations, specifically referencing RFO subparts 3.6 and 9.5 along with agency-specific requirements. The signatory must certify they have legal authority to bind the company and declare the statement true under penalty of perjury. Required completion fields include name, organization, date, phone, email, and signature.
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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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