D4 Conflict of Interest Statement.pdf
PDF 62 KB Posted
- Solicitation number
- 36C25624Q14651
About this file
This is a Conflict of Interest Statement form used for source selection evaluation board (SSEB) members and advisors for a VA procurement related to residential housing for Substance Use and Disorders Services (SUDS) in Little Rock, AR.
The form, effective February 1, 2022, requires SSEB participants to certify whether they or their immediate family members have any financial interests in companies bidding on the procurement. Members must disclose any friendships, family/social relationships, employment relationships, or other arrangements that could compromise independent judgment. The form includes checkboxes for declaring presence or absence of conflicts, spaces for describing any financial interests or relationships that could create conflicts, and fields for the member's name, organization, phone number, signature and date.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| D1 Quality Assurance Surveillance Plan.pdf | ||
| D3 Contractor Certification.pdf | ||
| RFQ 36C25624Q1465_1.pdf | ||
| D2 WD 2015-5117 Revision 25 Dated 7-22-24.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Effective Date: 02/01/2022
Conflict of Interest Statement
______________________________________________SOURCE SELECTION
(Insert acquisition name)
Please review the list of prime contractors and their subcontractors who are offering proposals in response to the Request for Proposal (RFP) for the acquisition identified above with the Contracting Officer. After reviewing the list, check the appropriate boxes, fill in the information requested, and sign:
o I certify that neither I nor my immediate family, to the best of my knowledge, possess any financial interest whatsoever in any company, parent or subsidiary, which is proposing on the acquisition identified above now being considered by the Source Selection Evaluation Board (SSEB) of which I am a member or advisor. Should any company in which I or my immediate family has a financial interest submit a proposal to my source selection team, I will immediately reveal such interest to the SSEB Chairperson and the Contracting Officer.
OR
o I do possess a financial interest in a company that is proposing on or is in a way involved in the acquisition identified above now being considered by the Source Selection Evaluation Board (SSEB) of which I am a member or advisor. (If you have checked this box, please provide a description of your financial interests on the reverse side of this form.) I further acknowledge my obligation to disclose any friendships; family or social relationships; past, present, or planned employment relationships, or any other type of relationship, such as housing or transportation arrangements, which might be perceived as compromising my independent judgment in connection with this Source Selection. (Please make any disclosures on the reverse of this form).
Name (print):____________________________________________
Organization: Phone:_____________________________________
Signature:_______________________________________________
Date:___________________________________________________
File details come from the government source that posted it. Updated .