Attachment 4 - Conflict of Interest Statement.pdf

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Attached to
Hesco Defense Barriers
Solicitation number
FA485526Q0086
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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 cannot award contracts to Government employees or organizations owned, substantially owned, or controlled by Government employees, as defined in 5 U.S.C. 2105. Respondents must certify whether they or any company owner/controller is a Government employee by selecting one of two checkbox options. The statement requires signatories to commit to disclosing any actual or potential conflicts of interest that arise during the engagement and to comply with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including RFO subpart 3.6, RFO subpart 9.5, and agency-specific requirements. The individual signing the form must have legal authority to bind the company and declares the certification under penalty of perjury. Required completion fields include the signatory's name, date, organization, phone number, email address, and signature.

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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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