Attachment 4 - Conflict of Interest Statement.pdf
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- Attached to
- Exhaust Troubleshooting
- Solicitation number
- FA485526Q0072
About this file
This is a Conflict of Interest Statement template required for federal contract proposals, designed to ensure compliance with Federal Acquisition Regulation (FAR) subpart 3.6 regarding contracts with Government employees or organizations owned or controlled by them.
The document serves as a certification mechanism requiring the signatory to declare under penalty of perjury whether they or any company member with ownership or substantial control interest is a Government employee, as defined in 5 U.S.C. 2105. The statement includes two mutually exclusive checkbox options: one certifying no Government employee affiliation and another certifying such affiliation exists. Additionally, the template obligates the submitting organization to promptly disclose any actual or potential conflicts of interest in writing to the Contracting Officer and cooperate with any required mitigation measures. Signatories must commit to compliance with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including FAR subpart 3.6 and FAR subpart 9.5, as well as agency-specific requirements. The document requires completion of standard identification fields including the signatory's name, date, organization, phone, email, and signature from an individual with legal authority to bind the company.
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Text version
ATTACHMENT 4 – CONFLICT OF INTEREST STATEMENT
Pursuant to Federal Acquisition Regulation (FAR) 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 FAR subpart 3.6 and FAR 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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