ESBD_485051_1769528321036_Exhibit D - Conflict of Interest Disclosure 301-26-03905D.pdf
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- Solicitation number
- 301-26-03905D
- Issued by
- Texas
About this file
This is a Conflict of Interest Disclosure form for RFP No. 301-26-03905D issued by the State of Texas. The document serves as a mandatory certification requirement that respondents must complete, sign, and submit with their proposals to avoid disqualification. Respondents are required to acknowledge their understanding of conflict of interest provisions, certifications, and statutes referenced in the RFP, specifically those outlined in Part B, Sections 14, 16, 21, and 54, which address prohibited bids and contracts, gifts to public servants, conflicts of interest disclosures, and compliance with applicable laws.
Respondents must certify that they, their employees, and subcontractors do not have any interests that would create conflicts of interest or impair their ability to perform contract obligations, or disclose any actual or potential conflicts if they exist. The form requires compliance with three specific Texas Government Code sections: Section 669.003 (restrictions on contracting with executive heads of state agencies), Section 572.069 (prohibiting employment of state officers and employees involved in procurement), and Section 2252.901 (contracts with former or retired agency employees). If any of these statutes apply, respondents must provide detailed information including the name of the former executive or employee, the relevant state agency, dates of separation and employment. Respondents bear a continuing duty to supplement disclosures with updated information if circumstances change or additional relevant information is obtained after proposal submission.
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Text version
RFP No. 301-26-03905D
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
File details come from the government source that posted it. Updated .