Local Assistance Procedures Manual EXHIBIT 10-T Conflict of Interest & Confidentiality Statement

EXHIBIT 10-T CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT

RFP/RFQ PROCUREMENT NUMBERS: ____________________________

PROJECT NAME:

APPLICABILITY: Applicable to local agency consultant procurements which will contain Federal or State funds in the consultant contract.

□ I am an employee of the local agency that is involved in this procurement.

□ I am an employee of a consultant under contract to the local agency that is responsible for this procurement but I am not in a management position with the local agency.

□ I have a personal, financial, or business interest in past employment activity or a personal relationship regarding the firms (including subconsultants) that are the subject of this evaluation. A brief description is provided on the back of this form.

□ I certify that I have no current contractual relationship with any of the firms (including subconsultants) that are the subject of this evaluation.

□ I certify that I have no personal or financial interest and no present or past employment activity or personal relationship or prior contractual relationship which would be incompatible with my participation in this solicitation process and I am fully able to give full, fair and impartial consideration to all proposals/bids as an appointee to the related evaluation.

□ I certify that I have read 23 CFR 172.7(b)(4) below and I agree not to participate in selection, or in the award or administration of a contract supported by Federal funds if a conflict of interest, real or apparent, would be involved.

23 CFR 172.7(b)(4)

(4) Conflicts of interest. (i) A contracting agency shall maintain a written code of standards of conduct governing the performance of their employees engaged in the award and administration of engineering and design related services contracts under this part and governing the conduct and roles of consultants in the performance of services under such contracts to prevent, identify, and mitigate conflicts of interest in accordance with 2 CFR 200.112, 23 CFR 1.33 and the provisions of this paragraph (b)(4).

(ii) No employee, officer, or agent of the contracting agency shall participate in selection, or in the award or administration of a contract supported by Federal-aid funds if a conflict of interest, real or apparent, would be involved.

Such a conflict arises when there is a financial or other interest in the consultant selected for award by:

(A) The employee, officer, or agent;

(B) Any member of his or her immediate family;

(C) His or her partner; or

(D) An organization that employs or is about to employ any of the above.

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Local Assistance Procedures Manual EXHIBIT 10-T Conflict of Interest & Confidentiality Statement

(iii) The contracting agency's officers, employees, or agents shall neither solicit nor accept gratuities, favors, or anything of monetary value from consultants, potential consultants, or parties to subagreements. A contracting agency may establish dollar thresholds where the financial interest is not substantial or the gift is an unsolicited item of nominal value.

(iv) A contracting agency may provide additional prohibitions relative to real, apparent, or potential conflicts of interest.

(v) To the extent permitted by State or local law or regulations, the standards of conduct required by this paragraph shall provide for penalties, sanctions, or other disciplinary actions for violations of such standards by the contracting agency's officers, employees, or agents, or by consultants or their agents.

(vi) A contracting agency shall promptly disclose in writing any potential conflict of interest to FHWA.

□ I fully understand and agree to immediately disqualify myself as soon as I am aware of a conflict of interest that may compromise my fair and impartial consideration of the proposals/bids.

□ I certify that I will hold in the strictest confidence all bids, proposals, correspondence, memoranda, working papers, or any other media which has any bearing on, or disclose any aspect of, any respondent or potential respondent to the RFP/RFQ above. I will not discuss the evaluation process with anyone not involved in the evaluation process until its completion.

□ I fully understand that it is unlawful for a person to utilize any organization name or auxiliary organization information, which is not a matter of public record, for personal gain.

□ I fully understand that any violation of the above is a basis for disciplinary action, up to and including termination or referral to the appropriate authorities for further investigation.

□ I am aware that the following firms and subconsultants/subcontractors have submitted proposals in response to the above referenced solicitation:

List firms including subconsultants/subcontractors:

1.

2.

3.

4.

etc.

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Local Assistance Procedures Manual EXHIBIT 10-T Conflict of Interest & Confidentiality Statement

Date: __________________ Signed: ________________________________________

Name: ________________________________________

Title: _________________________________________

Dept./Local Agency: _____________________________

Employer: ___________________________________

CONTRACT ADMINISTRATOR’S REVIEW

I have reviewed the foregoing “Conflict of Interest and Confidentiality Statement” and have determined, according to the information provided, that this individual:

□ does not have a conflict of interest and can participate in the “Selection Panel”

□ does have a conflict of interest and cannot participate in the “Selection Panel”

Signed: ________________________________________ Date: __________________

Name: ________________________________________

Title: _________________________________________

Dept./Local Agency: _____________________________

Employer: _____________________________________

Distribution: Original – Local Agency Consultant File

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