Attachment 4 - Conflict of Interest Statement.pdf
PDF 186 KB Posted
- Attached to
- Skidsteer: EZ Patcher
- Solicitation number
- FA485526Q0014
About this file
This is a Conflict of Interest Statement template required for federal contract solicitation submissions under the Revolutionary FAR Overhaul (RFO) subpart 3.6.
The document establishes that the Government prohibits awarding contracts to Government employees or organizations owned, substantially owned, or controlled by one or more Government employees, with "employee" defined per 5 U.S.C. 2105. Respondents must select one of two certification checkboxes: either certifying that neither the signatory nor any company owner/controller is a Government employee, or disclosing that they or a company owner/controller is a Government employee. The statement requires signatories to commit to promptly disclosing any actual or potential conflicts of interest in writing to the Contracting Officer and cooperating with required mitigation measures. Signatories must also agree to comply with all applicable federal ethics, procurement integrity, and conflict of interest regulations, including RFO subparts 3.6 and 9.5, plus any agency-specific requirements. The document requires completion of fields for the signatory's name, date, organization, phone, email, and signature, with the signatory declaring under penalty of perjury that they have authority to legally bind the company and that the certification is true and correct to the best of their knowledge.
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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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