Attachment 4 - Conflict of Interest Statement.pdf
PDF 186 KB Posted
- Attached to
- Air Compressor
- Solicitation number
- FA485526Q0064
About this file
This is a Conflict of Interest Statement form required as part of a federal contract solicitation under the Revolutionary FAR Overhaul (RFO) subpart 3.6.
The form requires the signatory to certify whether they or any member of the company with ownership or control interest are employees of the federal government. The Government is prohibited from awarding contracts to Government employees or organizations owned, substantially owned, or controlled by Government employees, with "Employee" defined per 5 U.S.C. 2105. The form includes two mutually exclusive certification options: one stating that neither the signatory nor any owner/controller is a Government employee, and an alternative stating that they are. Respondents must commit to promptly disclosing any actual or potential conflicts of interest in writing to the Contracting Officer and cooperating with mitigation measures. The form requires compliance 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 signatory must complete all fields including name, date, organization, phone, email, and signature, and declare under penalty of perjury that the certification is true and correct.
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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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