Attachment 4 Conflict of Interest Statement.pdf
PDF 134 KB Posted
- Attached to
- Exhaust Troubleshooting
- Solicitation number
- FA485526Q0038
About this file
This is a Conflict of Interest Statement template required for federal contract submissions pursuant to FAR subpart 3.6.
The statement requires the signatory to certify whether the company or its owners/controllers are Government employees, as the Government is prohibited from awarding contracts to Government employees or organizations substantially owned or controlled by them. The form includes two mutually exclusive certification options: one stating that neither the signatory nor company owners/controllers are Government employees, and an alternative stating that one or more are Government employees. The document 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. The signatory commits to compliance with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including FAR subpart 3.6 and FAR subpart 9.5, plus any agency-specific requirements. The form requires completion of name, date, organization, phone, email, and signature by an individual with legal authority to bind the company. The signatory makes the certification under penalty of perjury.
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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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