Attachment 6_WP3 OCI Declaration and Disclosure HT0038-21-S-C003.docx

HT003821R0001

HT0038-21-S-C003

Workplace 3.0 Attachment 6: Organizational Conflict of Interest Declaration and Disclosure

Solicitation Number: HT0038-21-S-C003 Program Executive Office, Healthcare Management Systems (PEO DHMS)

BACKGROUND

It is the Government’s intent to vet all offerors to ensure they do not have Organizational Conflicts of Interest (OCIs) such that the Government must disqualify an offeror from competing for this procurement. Please refer to Federal Acquisition Regulation Subpart 9.5. To that end, the Government requires that each offeror complete the following OCI Declaration and Disclosure Statement.

OFFEROR’S OCI DECLARATION AND DISCLOSURE

Failure to provide the enclosed OCI Declaration and Disclosure Statement, or omitting or misrepresenting information on the Statement, may result in the offeror being determined ineligible for award.

The undersigned, (Insert Name)_____, an authorized representative of ___(Insert Company Name)_____, (which is hereinafter referred to the “Company”), declares that my Company, including any entity[footnoteRef:1] on my team, to the best of my knowledge and belief, does not have an Organizational Conflict of Interest regarding solicitation HT0038-21-S-C003 as my Company has not: 1) had access to non-public information regarding solicitation HT0038-21-S-C003 that would assist my Company in obtaining the contract resulting from the solicitation, and 2) has not provided services under any Government contract that put my company in a position to influence the competition under solicitation HT0038-21-S-C003. [1: An Entity shall include the offeror, its affiliates and subsidiaries, joint venture partners, subcontractors, consultants, and vendors.]

-OR-

The undersigned, (Insert Name)_____, an authorized representative of ___(Insert Company Name)_____, (which is hereinafter referred to the “Company”) cannot declare that my Company, including any entity1 on my team, does not have an Organizational Conflict of Interest regarding solicitation HT0038-21-S-C003, as my Company does have information that is likely relevant to the Government’s assessment of whether my Company has an Organizational Conflict of Interest. Therefore, I have provided a disclosure statement[footnoteRef:2] attached to this form which describes all relevant information bearing on whether my Company may have an Organizational Conflict of Interest regarding solicitation HT0038-21-S-C003. [2: The document will identify the company, Governmental agency, contract number, dates of activity, the complete facts relevant to the potential type of conflict, mitigation plans, or other pertinent information for the Government’s consideration and review.]

SIGNATURE

[Company’s Name] [Authorized Representative’s Typed Name] [Title] [Date] image2.png image1.png