ESBD_385227_1734126895748_Exhibit D - Conflict of Interest Disclosure 301-24-04119.pdf

RFP No. 301-24-04119

EXHIBIT D

CONFLICT OF INTEREST

Disclosure

FAILURE TO COMPLETE, SIGN AND SUBMIT THIS EXECUTION OF PROPOSAL FORM

WITH RESPONDENT’S PROPOSAL MAY RESULT IN DISQUALIFICATION

RESPONDENT CONFLICT OF INTEREST DISCLOSURE AND CERTIFICATION

By signing this Conflict of Interest Disclosure and Certification, Respondent certifies and affirms the following:

1) Respondent has read and understands the various conflict of interests contract provisions, contract certifications, and conflict of interest statutes cited in the RFP, including, but not limited to, those contained in RFP Part B, Sections 14 (Prohibited Bids and Contracts), 16 (Gift to Public Servant), 21 (Conflicts of Interest; Disclosure of Conflicts; Disclosure of Interested Parties), and 54 (Compliance with Applicable Laws).

2) Except as otherwise disclosed in this Conflict of Interest Disclosure and Certification, Respondent, Respondents’ employees, and Respondents’ subcontractors do not have, nor shall they knowingly acquire, any interest that would create a conflict of interest, create the appearance of a conflict of interest, or be adverse to or conflict in any manner with the performance of Respondent’s obligations under any contract that may be awarded as a result of this RFP.

3) Complete only one the following check boxes as applicable:

Respondent discloses the following information that may present an actual or potential conflict of interest:

Respondent does not have any actual or potential conflicts of interest to disclose.

4) Respondent is compliant, and will remain in compliance during the term of any contract that may be awarded as the result of this RFP, with the following Sections of the Texas Government Code: Section 669.003 (Restriction on Contracting with Executive Head of State Agency); Section 572.069 (Prohibiting employment of state officers and employees who participated in the procurement of services); and Section 2252.901 (Contracts with Former or Retired Agency Employees). If any of these statutes apply, the Respondent shall complete the following information in order for its proposal to be evaluated:

Name of Former Executive or Employee: ____________________________________________________

Name of State Agency: ____________________________________________________

Date of separation from State Agency: ____________________________________________________

Date of employment with Respondent: ____________________________________________________

5) If the circumstances of the disclosures certified by Respondent change or additional information is obtained subsequent to the submission of Proposals, Respondent agrees that it is under a continuing duty to supplement its response under this provision, and Respondent shall submit updated information as soon as reasonably possible upon learning of any change to information contained in this disclosure and certification.

Signature - Authorized Bidder Representative

Printed Name Date