DCFS Specific Disclosures - Offeror and Subs~3.docx
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- Solicitation number
- 21-418DCFS-PROCU-B-24914
- Issued by
- St. Clair County, Illinois
About this file
This document is related to a specific disclosure form required by the Illinois Department of Children and Family Services (DCFS) for a CCWIS IV&V Services contract opportunity. The disclosure form covers potential conflicts of interest related to related party transactions and the contracting entity's history of debarment, legal proceedings, and other adverse actions. The related state and local contract opportunity is for DCFS CCWIS IV&V Services, which includes technical compliance, quality assurance, strategic planning, project advisory/consulting, risk management, and IT auditing. The contract term and any renewal options are not specified. Pricing is to be submitted separately under a different bid number. The disclosure form must be completed and signed by an authorized representative of the bidding entity, regardless of the annual bid or contract value.
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DCFS SPECIFIC STEP 8a
POTENTIAL CONFLICTS OF INTEREST FOR RELATED PARTY TRANSACTIONS
NOTE: For purposes of Steps 8 and Step 9 of this Contract, Key Management Staff is defined to include the top three highest paid staff funded under this Contract and the top persons managerially responsible for the services under this Contract.
Does any Key Management Staff receive compensation or payment in any form from another organization? |_| Yes |_| No If so, name the employee and the other organization, the position held, the amount of annual compensation or type of payment, and the date when the employee began receiving such compensation or payment. Please include an attachment if necessary with requested information in a format substantially similar to the format below; please reference DCFS Specific Step 8a.
| Name of Staff, |
| Other Organization |
| Work Hours, Compensation and Date of Hire for Other Organization |
Does any Key Management Staff, Officer, Board Member, owner or majority stockholder (or members of their immediate families, i.e., spouse, father, mother, son, or daughter):
Hold an ownership interest in an organization that leases, subcontracts, or provides services or materials to you paid in whole or in part from funds generated by this Contract?; |_| Yes |_| No Serve as an executive officer or board member of an organization that subcontracts or provides services or materials to you paid in whole or in part from funds generated by this Contract?; |_| Yes |_| No Serve as an employee of an organization that subcontracts or provides services or materials and part of his/her job duties include performing services related to the subcontract or the provision of services or materials to the organization for which he/she is a board member |_| Yes |_| No If you answered yes to 1, 2, or 3 above, disclose the name of the individual(s), the organization(s), the nature of the lease(s), materials, services or subcontract(s). Please include an attachment if necessary with requested information in a format substantially similar to the format below; please reference DCFS Specific Step 8a.
| Name of Staff, Board Member, Owner or Stockholder |
| Organization Leasing, Contracting, Providing Services or Materials |
| Nature of Lease, Services, Material or Subcontract |
DCFS SPECIFIC STEP 9a
POTENTIAL CONFLICTS OF INTEREST
RELATING TO DEBARMENT & LEGAL PROCEEDINGS
(All vendors complete regardless of annual bid, offer, or contract value) Please provide the name of the person or entity for which responses are provided: __________________________________________________________________________________
| 1. Has any Key Management Staff or the Contracting Entity been debarred or suspended, or otherwise excluded or ineligible from participation in federal assistance programs or under other statutory or regulatory compliance requirements from contracting with any governmental entity? |
| |_| Yes |_| No |
| 2. Have any Key Management Staff had adverse action taken in relation to a professional license? |
| |_| Yes |_| No |
| 3. Has the Contracting Entity had any bankruptcies? |
| |_| Yes |_| No |
| 4. Has the Contracting Entity had any adverse civil judgments and administrative findings? |
| |_| Yes |_| No |
| 5. Has the Contracting Entity or any Key Management Staff had any criminal felony convictions? |
| |_| Yes |_| No |
If you answered “Yes”, please provide a detailed explanation that includes, but is not limited to the name, entity, and position title of each individual. Please include an attachment if necessary with requested information in a format substantially similar to the format below; please reference DCFS Specific Step 9a.
| Name |
| Position |
| Organization |
| Nature of Proceedings |
| Date of Proceedings |
SIGN THE DISCLOSURE
(All vendors must complete regardless of annual bid, offer, or contract value)
This disclosure is signed, and made under penalty of perjury, by an authorized officer or employee on behalf of the bidder offer or/Vendor pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code. This disclosure information is submitted on behalf of Name of Disclosing Entity:
Signature: Date:
Printed Name:
Title:____________________________________________Phone Number________________________
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