Attachment 5_OCI_form.pdf

PPL-OCI-Certification (04/2016) (page 1 of 2)

I. REPRESENTATION/DISCLOSURE STATEMENT OF THE OFFEROR

[Explanation: The Offeror must complete either A or B of this section, but not both of the following Statements. If the Offeror perceives no OCI in connection with its organization's performance of the Statement of Work under this solicitation, the block for the OCI Representation Statement at subsection A should be checked. If the Offeror has identified possible OCI in connection with its organization's performance of the Statement of Work, the block for the OCI Disclosure Statement at subsection B should be checked, and the relevant information disclosed.]

A. OCI Representation Statement

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, no facts exist relevant to any past (within the past twelve months), present, or currently planned interest or activity (financial, contractual, personal, organizational or otherwise) which relate to the proposed work; and bear on whether I have (or the organization has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice; or (2) being given an unfair1 competitive advantage.

B. OCI Disclosure Statement

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, all relevant facts - - concerning past (within the past twelve months), present or currently planned interests or activities (financial, contractual, organizational or otherwise) which relate to the proposed work and bear on whether I have (or the organization has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or

1 An unfair competitive advantage does not include the normal flow of benefits from the performance of the subcontract.

ORGANIZATIONAL CONFLICTS OF INTEREST (OCI) CERTIFICATION

25-004

PPL-OCI-Certification (04/2016) (page 2 of 2) advice, or (2) being given an unfair1 competitive advantage - are fully disclosed on the attached _____ page (s) and formatted to show:

• For ease of presentation, divide following data into four parts: Organizational, contractual, financial, other;

• The company, agency, organization in which you have a past (within the past twelve months), present, or currently planned interest or activity (financial, contractual, organizational, or otherwise);

• A brief description of relationship;

• A period of relationship;

• The extent of relationship (e.g., value of financial interest of work; percent of total holdings, total work, etc.).

II. LOWER-TIER -SUBCONTRACTOR/CONSULTANT OCI

Any lower-tier subcontractor or consultant identified in the Offeror's proposal who would perform evaluation services or activities, technical consulting services, or management support services similar to those to be performed by the Offeror has completed and signed an Organizational Conflict of Interest (OCI) Certification, also known as the “Representation/Disclosure Statement of the Offeror” (subsection I.A. or I.B. above), as appropriate, pertaining to its participation in the performance of the Statement of Work. Each such signed Statement is attached.

SIGNATURE:_____________________________________ DATE:_____________________

PRINTED NAME:__________________________________ TITLE:_____________________

ORGANIZATION:________________________________________________________________