D.4. Attachment Organizational Conflict of Interest.pdf
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- Solicitation number
- 36C25026Q0466
About this file
This is a Contractor Conflict of Interest Certification Statement template for Veterans Administration Medical Center (VAMC) solicitations. The form requires contractors to certify whether they have any past, present, or currently planned financial, contractual, organizational, or other interests that could constitute actual or potential conflicts of interest related to the services being procured.
Contractors must select one of two options: either certify that no individuals involved in the solicitation have conflicts of interest, or attach a detailed statement describing all relevant facts concerning any actual or potential conflicts. If conflicts exist, the contractor must provide the same conflict of interest information for all identified consultants and subcontractors that will provide services under the solicitation. The form also allows contractors to explain how their organizational and management systems would mitigate any identified conflicts. The certification must be signed by an authorized official with their name, title, and date provided.
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Text version
Organizational Conflict of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION #
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that no individuals involved with the solicitation [____Solicitation # and Service Type___] in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___[NAME OF VAMC] _________ Veterans Administration under the referenced solicitation.
None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the___NAME OF VAMC _________ Veterans Administration under the referenced solicitation.
OR
[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.
NAME OF CERTIFYING OFFICIAL
TITLE
SIGNATURE DATE
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