ESBD_493478_1772498526574_RFP 301-26-03430 Exhibit D - Conflict of Interest Disclosure.pdf
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- Solicitation number
- RFP-301-26-03430
- Issued by
- Travis County, Austin City, Texas
About this file
This is a Conflict of Interest Disclosure and Certification form (Exhibit D) for RFP No. 301-26-03430 issued by the State of Texas. The form is a mandatory execution document that must be completed, signed, and submitted with a respondent's proposal; failure to do so may result in disqualification. Respondents are required to certify that they have read and understand the conflict of interest provisions, contract certifications, and conflict of interest statutes referenced in the RFP, including those in Part B Sections 14, 16, 21, and 54. The form requires respondents to disclose whether they, their employees, or their subcontractors have any actual or potential conflicts of interest that would interfere with performance of contract obligations, or to certify that no such conflicts exist.
The disclosure form additionally requires respondents to confirm compliance with specific Texas Government Code sections, including Section 669.003 (restrictions on contracting with executive heads of state agencies), Section 572.069 (prohibitions on 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 to the respondent, detailed information must be provided including the name of the former executive or employee, the state agency involved, the date of separation, and the date of employment with the respondent. The form includes a continuing duty clause requiring respondents to supplement their disclosure if circumstances change or additional information is obtained after proposal submission. The document requires signature and printed name of an authorized bidder representative along with the date of execution.
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Text version
RFP No. 301-26-03430
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 .