Attachment_O_-_Conflict_of_Interest_Disclosure_Statement.pdf
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- Solicitation number
- DCAM-26-CS-RFP-0007
- Issued by
- District of Columbia
About this file
This is a Conflict of Interest Disclosure Statement form issued by the District of Columbia Department of General Services (DGS) on behalf of the Department of Human Services (DHS) for the Construction Management at Risk (CMAR) services RFP for The Heritage - New York Avenue Shelter project located at 1201 New York Avenue NE, Washington, DC 20002. The form requires offerors and their team members, including principal participants, proposed subconsultants, subcontractors, chief executives, directors, and key personnel, to disclose all relevant facts relating to past, present, or planned interests that may result in or be perceived as organizational conflicts of interest in connection with the RFP.
Offerors must disclose current contractual relationships with DGS, past, present, or planned contractual or employment relationships with any officer or employee of the Department, and any other circumstances that might create a financial interest in the agreement for any Department member, officer, or employee. Additional disclosures include common directors with individuals or entities involved in preparing the RFP, contractual relationships such as joint ventures with such parties, and any relationships wherein such individuals or entities serve as contractors, consultants, subcontractors, or subconsultants to the offeror or team members. The undersigned must certify that, to the best of their knowledge and belief, no required interests exist other than those disclosed in the statement.
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Text version
CONFLICT OF INTEREST DISCLOSURE STATEMENT
Offeror’s Name: (“Offeror(s)”)
Offeror’s attention is directed to Section 4705 and Section 4707 of the Department of General
Services Procurement Rules for Construction and Related Services regarding organizational conflicts of interest (“Organizational Conflicts of Interest”). Offerors are advised that certain firms will not be allowed to participate in the Project or on any Offeror’s team for the Project because of their work with the Department in connection with the Project procurement.
(Initially capitalized terms not otherwise defined herein shall have the meanings set forth in the
Agreement or the RFP).
Required Disclosure of Conflicts
In the space provided below identify all relevant facts relating to past, present, or planned interest(s) of the Offeror’s team (including the Offeror, principal/major participants, proposed subconsultants and proposed subcontractors, and their respective chief executives, directors, and other key personnel for the Project) which may result, or could be viewed as, an Organizational
Conflict of Interest in connection with the RFP.
Offeror should disclose: (a) any current contractual relationships with the Department, (b) any past, present, or planned contractual or employment relationships with any officer or employee of Department, and (c) any other circumstances that might be considered to create a financial interest in the Agreement by any Department member, officer or employee if Offeror is awarded the Contract. Offeror should also disclose matters such as having directors in common with any of the individuals or entities involved in preparing the RFP. Offeror should also disclose contractual relationships (i.e. Joint Ventures) with any of the individuals or entities involved in preparing the RFP, as well as relationships wherein such individual or entity is a contractor or consultant (or subcontractor or subconsultant) to Offeror or a member of Offeror’s team. The foregoing is provided by way of example, and shall not constitute a limitation on the disclosure obligations.
Certification
The undersigned hereby certifies that, to the best of his or her knowledge and belief, no interest exists that is required to be disclosed in this Conflict of Interest Disclosure
Statement, other than as disclosed above.
Signature
Name
Title
Company Name
, 2022 Date
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