Attachment G - Non Disclosure Agreement_Conflict of Interest Statement.docx

CERTIFICATE FOR PERSONNEL PARTICIPATING IN AN ACQUISITION CONCERNING NON-DISCLOSURE AND DISCLOSURE OF CONFLICTS OF INTEREST

Name: ___________________________

Organization: ____________________________

Title of Requirement: _________________ Evaluations NDA and COI Statement

PART A – NON-DISCLOSURE AGREEMENT

1. I acknowledge that I have been selected to participate in the acquisition identified above. In the course of participating in this acquisition, I may be or have been given access to or entrusted with Source Selection Information (as defined in Federal Acquisition Regulation (FAR) 3.104), other sensitive Government data such as data identified as "Business Sensitive," and/or data belonging to or marked or considered as "proprietary" (e.g., restrictive legend per FAR 52.215-1) that I cannot release to others nor can I use for the financial benefit of others or myself.

Data includes all data, information and software, regardless of the medium (e.g. electronic or paper) and/or format in which the data exists, and includes data which is derived from, based on, incorporates, includes or refers to such Source Selection, Business Sensitive and/or proprietary data (collectively referred to herein as "the data"). Any data which is derived from, based on, incorporates, includes or refers to data shall be treated as Source Selection, Business Sensitive or proprietary data and shall be subject to the terms of this Non-Disclosure Agreement.

1. I understand that the release of proprietary and source selection information is governed by 41 U.S.C. § 423, and provisions FAR 3.104. I certify that I will not disclose any contractor bid, solicitation, proprietary, or source selection information directly or indirectly to any person other than a person authorized by the head of agency or the contracting officer to receive such information. I understand that unauthorized disclosure of such information may subject me to substantial administrative, civil and criminal penalties, including fines, imprisonment, and loss of employment under the Procurement Integrity Law or other applicable laws and regulations.

1. I certify that I will not discuss evaluation of source selection matters with any unauthorized individuals (including Government personnel), even after contract award, without specific prior approval from proper authority.

1. These restrictions are consistent with, and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by:

1. Executive Order No. 12958;

1. The Privacy Act (5 U.S.C. § 552a);

1. The Trade Secrets Act (18 U.S.C. § 1905);

1. Section 7211 of title 5, United States Code (governing disclosures to Congress);

1. Section 1034 of title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military);

1. Section 2302(b)(8) of title 5, United States Code, as amended by the Whistleblower Protection Action (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats);

1. The Intelligence Identities Protection Act of 1982 (50 U.S.C. § 421 et seq.) (governing disclosures that could expose confidential Government agents); and

1. The statutes which protect against disclosure that may compromise the national security, including sections 641, 793, 794, 798, and 952 of title 18, United States Code, and section 4(b) of the Subversive Activities Act of 1950 (50 U.S.C. § 783(b)).

The definitions, requirements, obligations, rights, sanctions, and liabilities created by said Executive order and listed statutes are incorporated into this agreement and are controlling. In addition, these restrictions do not bar disclosures to Congress or to an authorized official of an executive agency or the Department of Justice that are essential to reporting a potential violation of law.

PART B – ACKNOWLEDGEMENT OF CONFLICT OF INTEREST

1. I understand and will abide by Criminal Conflict of Interest law at title, 18 United States Code, Chapter 11, and the Standards of Conduct for Executive Branch Employees at 5 C.F.R. Part 2635. Consistent with the criminal conflict of interest law, I will: 1) notify the Contracting Officer if any potential conflict subsequently arises because I or my spouse, dependent child, partner, or any organization which I am serving as an officer, director, trustee, general partner, or employee, or any person or organization with whom I am negotiating or have an arrangement concerning prospective employment, has a financial interest in this acquisition and; 2) recuse myself from further participation in the acquisition unless and until I am advised that it is permissible to do so.

1. Consistent with the Standards of Conduct I will: 1) notify the Contracting Officer if any potential appearance of a conflict of interest arises because a person with whom I have a “covered relationship” is or represents a party to this acquisition and; 2) recuse myself from further participation in the acquisition unless and until I am advised that it is permissible to do so. Understand that I have a “covered relationship” with all those persons covered by the criminal conflict of interest law as well as: a member of my household; any relatives with whom I have a close personal relationship; any person with whom I have or seek a business, contractual or other financial relationship other than a routine consumer transaction; any personal for whom my spouse, parent or dependent child is, or is seeking to serve, as an officer, director, trustee, employee, general partner, agent, attorney, consultant contractor, or employee; any person for whom I have served in the last year as an officer, director, trustee, general partner, agent, attorney, consultant, contractor, or employee; or organization in which I am an active participant.

1. I understand that my obligations under this certification are of a continuing nature. If at any time during the source selection process, I receive a contact from a competing contractor concerning employment or other business opportunity, the offer of a gift from a competing contractor, or I encounter circumstances where my participation might result in a real, apparent, or potential conflict of interest, I will immediately seek the advice of an Ethics Counselor and report the circumstances to the Contracting Officer.

I agree to immediately notify the Contracting Officer in writing, in the event that I determine or have a reason to suspect a breach of this agreement, its’ requirements, or similar agreements with others.

I understand that making a false, fictitious, or fraudulent certification may subject me to prosecution under Title 18, United States Code, and Section 1001.

NOTIFICATION STATEMENT REQUIRED BY Whistleblower Protection Enhancement Act of 2012 (WPEA) These provisions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling.

Signature: ______________________________________ Date: ____________________

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