ATTM 006 ORGANIZATIONAL COI DISCLOSURE.docx
DOCX document 24 KB Posted
- Attached to
- NEMT MEDICAL TRANSPORTATION
- Solicitation number
- 5400029919
- Issued by
- Richland County, South Carolina
About this file
This is an Organizational Conflict of Interest Disclosure form for the State of South Carolina related to a NEMT Medical Transportation contract opportunity (RFP 54000). The form requires offerors to disclose any past, present, or currently planned interests—financial, contractual, organizational, or otherwise—that could bias their judgment or provide unfair competitive advantage in performing work under the solicitation. Offerors must provide a concise narrative statement describing all relevant facts concerning potential conflicts of interest, including those related to affiliates, proposed consultants, and subcontractors at any tier. If no conflicts exist, offerors must submit a certification stating that to their best knowledge and belief no such facts are relevant to possible organizational conflicts of interest.
The State reserves the right to review all submitted statements and request additional information as needed to determine whether an award would create an organizational conflict of interest. Failure to provide the required disclosure or representation, or nondisclosure and misrepresentation of relevant interests, may result in offeror disqualification, contract termination for default, disqualification from subsequent related contracts, or other remedial actions permitted by law. No award shall be made until the disclosure or representation has been evaluated by the State. The offeror must complete Part V by providing the offeror's name, signature, title, and date, along with the RFP number (RFP 54000).
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ATTM 006 Organizational Conflict of Interest Disclosure
| I. | INSTRUCTIONS | ||
| Read Part II carefully. If a disclosure statement is required, please provide a narrative statement in Part III. If a representation is submitted, please complete Part IV. Complete Part V in every case. | |||
| II. | ORGANIZATIONAL CONFLICT OF INTEREST DISCLOSURE OR REPRESENTATION | ||
| It is the policy of State of South Carolina (State) to avoid situations which place an Offeror in a position where its judgment may be biased because of any past, present, or currently planned interest, financial or otherwise, the Offeror may have which relates to the work performed pursuant to this solicitation or where the Offeror’s performance of such work may provide it with an unfair competitive advantage. (As used herein “Offeror” means the proposer or any of its affiliates or proposed consultants or subcontractors of any tier.) | |||
| Therefore: | |||
| (a) | The Offeror shall provide a statement which describes in a concise manner all relevant facts concerning any past, present or currently planned interest (financial, contractual, organizational, or otherwise) relating to the work to be performed hereunder and bearing on whether the Offeror has a possible organizational conflict of interest with respect to (1) being able to render impartial, technically sound, and other objective assistance or advise, or (2) being given an unfair competitive advantage. The Offeror may also provide relevant facts that demonstrate how possible organizational conflict of interest relating to other divisions or sections of the organization(s) or its existing organizational structure or system might be avoided or mitigated. This information should be provided in narrative form in Part III. | ||
| (b) | In the absence of any relevant interest referred to above, the Offeror shall submit a statement certifying that to its best knowledge and belief no such facts exist relevant to possible organizational conflicts of interest. The Offeror’s statement pursuant to this paragraph as well as any statement required to be submitted under (a) above shall include statements form proposed consultants and subcontractors at any tier if relevant. Offeror is responsible for submitting all such information as part of its certification. | ||
| (c) | The State will review the statement submitted and may require additional relevant information from the Offeror. All such information, and any other relevant information will be used by State to determine whether an award to the Offeror may create an organizational conflict of interest. If found to exist, State may (1) impose appropriate conditions which avoid such conflict, (2) disqualify the Offeror, or (3) determine that it is otherwise in the best interest of the State to contract with the Offeror by including appropriate conditions mitigating such conflict in the contract awarded. | ||
| (d) | The refusal to provide the disclosure or representation of any additional information as required shall result in disqualification of the Offeror for award. The nondisclosure or misrepresentation of any relevant interest may also result in the disqualification of the Offeror for award, or if such nondisclosure or misrepresentation is discovered after award, the State may terminate the contract for default, disqualify the contractor from subsequent related contracts, or subject the contractor to such other remedial actions as may be permitted or provided by law. | ||
| (e) | No award shall be made until the disclosure or representation has been evaluated by State. |
III. DISCLOSURE STATEMENT: (attach additional pages if more space is needed)
(Offeror to provide a concise narrative of any potential conflicts)
IV. REPRESENTATION
The Offeror, ___________________________________________________, hereby represents that it is aware of no past, present, or currently planned interest (financial, contractual, organizational, or otherwise) relating to the work to be performed under the contract resulting from Request for Proposal No. __________________________ that would indicate any impingement upon its ability to render impartial, technically sound, and objective assistance or advice or result in it being given an unfair competitive advantage. This representation applies to all affiliates of the Offeror and its proposed consultants or subcontractors of any tier.
V. SIGNATURE
| Offeror’s Name___________________________________________________________________ |
| RFP/Contract No. RFP 54000_______________ |
| Signature___________________________________________________________________ |
| Title_______________________________________________________________________ |
Date_______________________________________________________________________
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