Conflict of Interest Form- Fillable PDF.pdf

98 KB Posted

Attached to
Water Damage Repairs at 703 and 711 Atlantic Ave.
Solicitation number
2026-ITB-Water Damage IP-AHA-HD-009
Issued by
Alameda County, California

About this file

Written by GovTribe AI ·

This is a Conflict of Interest Certification form issued by the Housing Authority of the City of Alameda (AHA) for use by bidders, proposers, and vendors submitting bids for the Water Damage Repairs project at 703 and 711 Atlantic Avenue. The project involves water damage sustained from fire sprinkler activation at Independent Plaza, requiring replacement of drywall, cabinets, flooring, and other interior building components. Bids must be sealed and delivered to the AHA offices at 701 Atlantic Avenue by Wednesday, August 5, 2026, at 4:00 PM. A mandatory pre-bid conference is scheduled for Thursday, July 23, 2026, at 1:00 PM at the project site. Bid opening will occur on Thursday, August 6, 2026, at 1:00 PM at the Independence Plaza Community Room. The AHA encourages minority-owned, women-owned, and emerging small business participation.

The Conflict of Interest Certification requires bidders to disclose any personal relationships, business or financial relationships, or organizational conflicts of interest with AHA current or former officials, officers, employees, or their immediate family members and business associates. Bidders must also list any other projects currently underway in the City of Alameda. The form requires the authorized official or representative of the bidding entity to certify under penalties of perjury that no actual or apparent conflicts of interest exist regarding the contract award and performance of services. The document does not contain information regarding pricing terms, contract value, funding sources, or specific set-asides beyond the general encouragement for participation by minority-owned and women-owned businesses.

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HOUSING AUTHORITY OF THE CITY OF ALAMEDA CONFLICT OF

INTEREST CERTIFICATION

(a) Does the Bidder/Proposer/Vendor have any current or prior personal relationships with AHA current or former official, officer or employee or their immediate family member or business associate to disclose?*

(b) Does the Bidder/Proposer/Vendor have any current or prior business or financial relationships with AHA current or former official, officer or employee or their immediate family member or business associate to disclose?*

(c) Does Bidder/Propose/Vendor have any current or prior relationship with AHA current or former official, officer or employee or their immediate family member or business associate to disclose?*

(d) Is there an organizational conflict of interest, whether actual or apparent that the Bidder/Proposer/Vendor is aware of, or there is reason to be aware of, at the time of this submittal concerning any past, present, or currently planned interest, financial, contractual, organizational, or otherwise, relating to the work to be performed hereunder?*

Additional projects in the City of Alameda*

Name of Bidder/Proposer/Vendor*

Yes No

Yes No

Yes No

Yes No

Please list any other projects you are currently working on in the City of Alameda.

7/10/26, 4:03 PM New Submission https://form.alamedahsg.org/Forms/A4Gpo 1/2

Address of Bidder/Proposer/Vendor*

Name of Authorized Official or Representative of Bidder/Proposer/Vendor*

Title of Authorized Official or Representative of Bidder/Proposer/Vendor*

Name of primary contact at AHA and/or project name*

Signature*

City State / Province / Region

Postal / Zip Code Country

Street Address

Address Line 2

The undersigned Bidder/Proposer/Vendor hereby certifies and affirms under penalties of perjury, that to the best of this Bidder/Proposer/Vendor’s knowledge and belief, no actual or apparent conflict of interest exists as to the award of the contract to Bidder/Proposer/Vendor and to the performance of contract services by Bidder/Proposer/Vendor as described in Parts I, II, and III of Part A of the certification. The undersigned official certifies that he/she is authorized to sign this bids/proposals form for the firm.

7/10/26, 4:03 PM New Submission https://form.alamedahsg.org/Forms/A4Gpo 2/2

Check Box1: Off
Check Box2: Off
Check Box3: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off
If yes, please explain:
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