Attachment 4 - Conflict of Interest Statement.pdf
PDF 134 KB Posted
- Attached to
- Exhaust Troubleshooting
- Solicitation number
- FA485526Q0032
About this file
This is a Conflict of Interest Statement template required for federal contract bidders and awardees. The document establishes compliance requirements under Federal Acquisition Regulation (FAR) subpart 3.6, which prohibits the government from awarding contracts to government employees or organizations substantially owned or controlled by government employees. The statement requires the signatory to certify under penalty of perjury whether they or any company owner/controller is a government employee as defined in 5 U.S.C. 2105, with two checkbox options provided for disclosure of employee status.
The document obligates the contractor to promptly disclose any actual or potential conflicts of interest in writing to the Contracting Officer and to comply with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including FAR subpart 3.6 and FAR subpart 9.5. The statement requires completion by an individual with authority to legally bind the company and must include the signatory's name, organization, date, phone number, email address, and signature. This is a template document intended for use in federal contract solicitations.
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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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