ATTACHMENT C Affidavit of Non-conflict of interest.pdf
PDF 65 KB Posted
- Solicitation number
- DQ1 TFAA 2016000681 2
- Issued by
- Colorado
About this file
This is a Conflict of Interest Affidavit for the Colorado Department of Revenue, Lottery Division, related to Documented Quote #LOT160011-ADS concerning Automated Drawing Systems (ADS) contractors. The affidavit establishes conflict of interest disclosure and management requirements for employees, officers, staff members, temporary employees, and subcontractors of awarded contractors. Signatories must certify their ability to perform services in a fair, impartial, and independent manner while adhering to State of Colorado and Department of Revenue guidelines and procedures. The document requires disclosure of any financial interests, direct or indirect, with lottery ADS contractors, subcontractors, or subsidiaries for State evaluation.
The affidavit prohibits employees and subcontractor staff from representing, assisting, or acting in any capacity for potential offerors responding to the ADS solicitation. Signatories must disclose any communications asserting conflicts of interest to the State and agree to resign accounts if the State determines conflicts exist with State interests, including accounts becoming matters of public controversy or those in direct competition with State Lottery business. Employees further agree not to accept accounts from clients offering conflicting products or services, such as other legal gaming entities, without prior written State consent. Any situation creating the appearance of conflict or impropriety must be reported immediately to the Lottery Security Director at (719) 546-5212. The affidavit requires the signature, printed name, title, and company name of the certifying individual.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT A DQ- Confirmation of Offer.pdf | ||
| ATTACHMENT D Statement of Confidentiality.pdf | ||
| ATTACHMENT B Pricing .pdf | ||
| DQ DOR160011-ADS (10) - docx.pdf |
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Text version
Attachment C
Conflict of Interest
Colorado Department of Revenue, Lottery Division
Documented Quote #LOT160011-ADS
As an employee, officer, staff member, temporary employee or subcontractor of
________________, (“Contractor”), I hereby certify that I will perform and conduct services under the guidelines, procedures, policies and requirements of the State of Colorado or the Department of Revenue, State Lottery Division (“State”) and this award as a fair and impartial participant.
I hereby certify that I have no conflicts of interest. Further, I represent as follows:
1. I promise to conduct the services in this award in an independent, impartial and responsive manner.
2. I will disclose the nature and extent of any financial interests (direct or indirect) with any lottery
Automated Drawing Systems contractors, subcontractors, or subsidiaries to the State for its evaluation of the significance of the financial interest on participation in this award. Except as I shall disclose in detail, I neither have nor shall I during the award acquire any financial interest that would conflict in any manner or degree with my responsibilities.
3. As an employee of the Contractor and/or its subcontractors, I shall not represent, assist or act in any capacity for any potential offerors who may respond to the ADS solicitation, including responding to the DQ myself.
4. As an employee of the Contractor and/or its subcontractors, I shall be responsible for disclosing to the State receipt of any communication asserting any conflict of interest.
5. I agree to resign any accounts if the State, within its sole discretion, determines that such accounts are in conflict with the best interests of the State. Examples of such conflicts would be accounts that become matters of public controversy that could reflect negatively on the State or accounts that are in direct competition with the State Lottery’s business. Furthermore, during the term of the award, I agree that I will not accept the account of any other client having a conflicting product or service (such as another legal gaming entity) as determined by the State, without the prior written consent of the State. Consent will not be unreasonably withheld.
If I should become aware of any situation that may arise, that could alter any of the representations above, or that might otherwise create the appearance of conflict or other impropriety, I shall notify the State immediately. Such notification shall be made to the Lottery Security Director, at (719) 546-5212
Signature Date
Print Name
Title
Company Name
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