Attachment H- Conflict of Interest Affidavit and Disclosure.pdf
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- Attached to
- Psychologist for MDH Potomac Center/SETT
- Solicitation number
- BPM031233
- Issued by
- Washington County, Maryland
About this file
The provided document is an Attachment H - Conflict of Interest Affidavit for a state and local contract opportunity from the Maryland Department of Health (MDH) to hire a Licensed Psychologist to work part-time, 10-12 hours per week, at the Potomac Center/SETT facility in Hagerstown, Maryland. The contract term is 25 weeks, to initiate on 9/7/2022. The Psychologist will be responsible for supervising Psychology Associates, overseeing administration and clinical services, providing psychology services to Individuals on the Cottages, and performing other assigned duties. The Potomac Center is an intermediate care facility (ICF) and the SETT is a forensic residential facility, both serving intellectually and/or developmentally disabled adults who are court ordered to the facilities and may have co-existing mental disorders.
The Conflict of Interest Affidavit requires the Offeror to disclose any relevant facts or circumstances that may give rise to a conflict of interest, either currently or in the future. The Offeror must affirm under penalty of perjury that the contents of the affidavit are true and correct to the best of their knowledge, information, and belief. The affidavit must be submitted with the bid or proposal for this state and local contract opportunity.
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Text version
Attachment H – Conflict of Interest Affidavit Page H-1 effective date: April 17, 2018
Attachment H. Conflict of Interest Affidavit and Disclosure
Reference COMAR 21.05.08.08
A. “Conflict of interest” means that because of other activities or relationships with other persons, a person is unable or potentially unable to render impartial assistance or advice to the State, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or a person has an unfair competitive advantage.
B. “Person” has the meaning stated in COMAR 21.01.02.01B (64) and includes a Offeror, Contractor, consultant, or subcontractor or sub-consultant at any tier, and also includes an employee or agent of any of them if the employee or agent has or will have the authority to control or supervise all or a portion of the work for which a Proposal is made.
C. The Offeror warrants that, except as disclosed in §D, below, there are no relevant facts or circumstances now giving rise or which could, in the future, give rise to a conflict of interest.
D. The following facts or circumstances give rise or could in the future give rise to a conflict of interest (explain in detail — attach additional sheets if necessary):
E. The Offeror agrees that if an actual or potential conflict of interest arises after the date of this affidavit, the Offeror shall immediately make a full disclosure in writing to the procurement officer of all relevant facts and circumstances. This disclosure shall include a description of actions which the Offeror has taken and proposes to take to avoid, mitigate, or neutralize the actual or potential conflict of interest. If the contract has been awarded and performance of the contract has begun, the Contractor shall continue performance until notified by the procurement officer of any contrary action to be taken.
I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE
CONTENTS OF THIS AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE, INFORMATION, AND BELIEF.
Date: ____________________ By: ______________________________________
(Authorized Representative and Affiant)
SUBMIT THIS AFFIDAVIT WITH BID/PROPOSAL
File details come from the government source that posted it. Updated .