DCFS Supplemental Disclosures and COI 230406~9.docx
DOCX document 18 KB Posted
- Attached to
- PO25-041, Statewide Fingerprinting Services TP
- Solicitation number
- 25-418DCFS-PROCU-B-43899
- Issued by
- Illinois
About this file
This document is a form related to potential conflicts of interest for a state and local contract opportunity issued by the Illinois Department of Children and Family Services (DCFS) to establish a multi-year master contract for background checks, photo identification, live scan, and ink fingerprinting services on an as-needed basis. It requires the vendor to disclose any Key Management Staff who receive compensation from other organizations, hold ownership interests in organizations that provide services or materials under the contract, or have been subject to debarment, license issues, bankruptcies, adverse civil judgments, or criminal felony convictions.
The contract opportunity has an ID of PO25-041 and is titled "Statewide Fingerprinting Services TP". The contract period and any renewal options are not specified. Pricing terms, set asides, incumbent information, funding requirements and sources are not detailed in this document.
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Text version
DCFS SPECIFIC STEP 8a
POTENTIAL CONFLICTS OF INTEREST FOR RELATED PARTY TRANSACTIONS
NOTE: For purposes of Steps 8 and 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(s), the position held, the amount of the 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 the requested information in a format substantially similar to the format below and 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):
| 1. |
| 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 |
| 2. |
| 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 |
| 3. |
| 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 the requested information in a format substantially similar to the format below and please reference DCFS Specific Step 8a.
| Name of Staff, Board Member, Owner, or Stockholder |
| Organization Leasing, Contracting, Providing Services, or Materials |
| Nature of Leases, Services, Materials, or Subcontracts |
DCFS SPECIFIC STEP 9a
POTENTIAL CONFLICTS OF INTEREST
RELATING TO DEBARMENT AND LEGAL PROCEEDINGS
(All Vendors must 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 any Key Management Staff or the Contracting Entity had any criminal felony convictions? |
| |_| Yes |_| No |
If you answered yes to any of the questions 1-5 above, 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 the requested information in a format substantially similar to the format below and 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, offeror, 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:
Email Address:
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