Attachment 4 - Conflict of Interest Statement.pdf
PDF 167 KB Posted
- Attached to
- B1820 TRANE Chiller Replacement
- Solicitation number
- FA485526Q0014
About this file
This document is a Conflict of Interest Statement form required for federal contract opportunities under the Revolutionary FAR Overhaul (RFO) subpart 3.6. The form establishes that the Government is prohibited from awarding contracts to Government employees or organizations substantially owned or controlled by Government employees, with "employee" defined as per 5 U.S.C. 2105.
The statement requires the signatory to certify under penalty of perjury whether they or any company owner/controller is a Government employee, with two checkbox options provided for disclosure. The form obligates the contractor to promptly disclose any actual or potential conflicts of interest in writing to the Contracting Officer and to cooperate with mitigation measures as needed. Additionally, the contractor commits to compliance with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including RFO subparts 3.6 and 9.5, as well as any agency-specific requirements. The form requires completion of fields for signatory name, organization, contact information, date, and signature by an individual authorized to legally bind the company.
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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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