Attachment_H-_Conflict_of_Interest_Affidavit_and_Disclosure.pdf
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- Solicitation number
- BPM048037
- Issued by
- Washington County, Maryland
About this file
This document is a Conflict of Interest Affidavit and Disclosure form (Attachment H) required by the State of Maryland, referencing COMAR 21.05.08.08, with an effective date of April 17, 2018. The form must be submitted with any bid or proposal for state contracts and requires offerors to disclose any actual or potential conflicts of interest that could impair their ability to provide impartial assistance or advice to the State, affect their objectivity in performing contract work, or create an unfair competitive advantage.
The document defines key terms including "conflict of interest" and "person" (which includes offerors, contractors, consultants, subcontractors, and their employees or agents), and requires immediate written disclosure to the procurement officer if any conflicts arise after submission. This affidavit applies to a part-time Speech Therapist position at MDH Potomac Center and SETT facilities in Hagerstown, Maryland, where the contractor will provide approximately 10 hours per week of speech therapy services over a 35-week period.
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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 .