Attachment D.2 - Contractor Organizational Conflict of Interest.pdf
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- Attached to
- Q201--Holly Springs CBOC Services Federal contract opportunity
- Solicitation number
- 36C24924R0063
About this file
This is a Contractor Organizational Conflict of Interest (OCI) certification form template related to a VA solicitation for Community Based Outpatient Clinic Services in Holly Springs, Mississippi. The form requires contractors to certify either that they have no present, planned, or past conflicts of interest regarding the services to be provided, or alternatively, to provide a detailed statement describing any relevant facts concerning potential conflicts.
The certification requires disclosure for key personnel, temporary emergency substitutions, consultants, and subcontractors who will provide services under the solicitation. If conflicts exist, contractors must explain how their organizational/management systems would avoid or mitigate potential conflicts. The form requires signature by a certifying official with their title and date. This is an appendix template (Attachment D.2) that does not itself specify services or requirements, but rather serves as a required certification document for bidders.
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Text version
Attachment D.2 – Contractor Organizational Conflict of Interest
APPENDIX A
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION #
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation [____Solicitation # and Service Type___] in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___[NAME OF VAMC] _________ Veterans Administration under the referenced solicitation.
None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the___NAME OF VAMC _________ Veterans Administration under the referenced solicitation.
OR
[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.
NAME OF CERTIFYING OFFICIAL
TITLE
SIGNATURE DATE
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