Exhibit R FL-11_Rev1.pdf

Organizational Conflict of Interest (OCI) Certification & Assessment (DEAR 952.209-72 / Prime Contract I.74 (f)) (Required for awards anticipated to exceed the Simplified Acquisition Threshold, in support of advisory and assistance services, as defined in FAR 2.101.)

Document Number: FL-11 Revision: 1

Page: 1 of 4

*For Offeror Use Only RFQ or RFP #:

I. REPRESENTATION/DISCLOSURE STATEMENT OF THE OFFEROR

The Offeror must complete either A or B of this section, but not both of the following Statements.

A. OCI Representation Statement – Choose if No perceived OCI exists

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, no facts exist relevant to any past (within the past twelve months), present, or currently planned interest or activity (financial, contractual, personal, organizational or otherwise) which relate to the proposed work; and bear on whether I have (or the organization has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice; or (2) being given an unfair1 competitive advantage.

B. OCI Disclosure Statement – Choose if Identified Possible OCI & disclose relevant info

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, all relevant facts - - concerning past (within the past twelve months), present or currently planned interests or activities (financial, contractual, organizational or otherwise) which relate to the proposed work and bear on whether I have (or the organization has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice, or

(2) being given an unfair1 competitive advantage - - are fully disclosed on the attached page (s) and formatted to show:

• For ease of presentation, divide following data into four parts: Organizational, contractual, financial, other;

• The company, agency, organization in which you have a past (within the past twelve months), present, or currently planned interest or activity (financial, contractual, organizational, or otherwise);

• A brief description of relationship;

• A period of relationship;

• The extent of relationship (e.g., value of financial interest of work; percent of total holdings, total work, etc.).

1 An unfair competitive advantage does not include the normal flow of benefits from the performance of the subcontract.

Organizational Conflict of Interest (OCI) Certification & Assessment (DEAR 952.209-72 / Prime Contract I.74 (f)) (Required for awards anticipated to exceed the Simplified Acquisition Threshold, in support of advisory and assistance services, as defined in FAR 2.101.)

Document Number: FL-11 Revision: 1

Page: 2 of 4

II. SUB-SUBCONTRACTOR/CONSULTANT OCI

Any sub-subcontractor or consultant identified in the Offeror's proposal who would perform evaluation services or activities, technical consulting services, or management support services similar to those to be performed by the Offeror has completed and signed either an OCI Representation Statement or an OCI Disclosure Statement (subsection I.A. or I.B. above), as appropriate, pertaining to its participation in the performance of the Statement of Work. Each such signed Statement is attached.

SIGNATURE:

PRINTED NAME:

DATE:

TITLE:

ORGANIZATION:

Organizational Conflict of Interest (OCI) Certification & Assessment (DEAR 952.209-72 / Prime Contract I.74 (f)) (Required for awards anticipated to exceed the Simplified Acquisition Threshold, in support of advisory and assistance services, as defined in FAR 2.101.)

Document Number: FL-11 Revision: 1

Page: Page 3 of 4

*For Fermi Forward Discovery Group, LLC of General Counsel (OGC) Use Only

FERMILAB OCI FINDING

The Offeror's proposal and enclosed OCI representation/certification (disclosure) have been reviewed and:

The Laboratory finds that a conflict does NOT exist

The Laboratory finds that a conflict exists, but adoption of the measure(s) specified below will adequately avoid the conflict.

The Laboratory finds that a conflict exists, that it cannot be avoided adequately, and that award should not be made.

The Laboratory finds that a conflict exists and cannot be satisfactorily avoided, but recommends that DOE approve award in face of the conflict for the reasons set forth below:

Discussion/Rationale for Finding above:

Buyer:

Signature

Printed or Typed Name Date

OGC:

Signature

Printed or Typed Name Date

DOE:

Signature

Printed or Typed Name Date

Organizational Conflict of Interest (OCI) Certification & Assessment (DEAR 952.209-72 / Prime Contract I.74 (f)) (Required for awards anticipated to exceed the Simplified Acquisition Threshold, in support of advisory and assistance services, as defined in FAR 2.101.)

Document Number: FL-11 Revision: 1

Page: Page 4 of 4

General Instructions for using this form:

1.0 Requirements:

This form shall be completed by Offerors for all awards, or modifications, expected to exceed the simplified acquisition threshold for work being performed in support of advisory and assistance services.

Advisory and Assistance Services are defined (FAR 2.101) as:

Those services provided under contract by nongovernmental sources to support or improve organizational policy development; decision-making; management and administration; program and/or project management and administration; or R&D activities. It can also mean the furnishing of professional advice or assistance rendered to improve the effectiveness of Federal management processes or procedures (including those of an engineering and technical nature). In rendering the foregoing services, outputs may take the form of information, advice, opinions, alternatives, analyses, evaluations, recommendations, training and the day-to-day aid of support personnel needed for the successful performance of ongoing Federal operations. All advisory and assistance services are classified in one of the following definitional subdivisions:

(1) Management and professional support services, i.e., contractual services that provide assistance, advice or training for the efficient and effective management and operation of organizations, activities (including management and support services for R&D activities), or systems. These services are normally closely related to the basic responsibilities and mission of the agency originating the requirement for the acquisition of services by contract. Included are efforts that support or contribute to improved organization of program management, logistics management, project monitoring and reporting, data collection, budgeting, accounting, performance auditing, and administrative technical support for conferences and training programs.

(2) Studies, analyses and evaluations, i.e., contracted services that provide organized, analytical assessments/evaluations in support of policy development, decision-making, management, or administration.

Included are studies in support of R&D activities. Also included are acquisitions of models, methodologies, and related software supporting studies, analyses or evaluations.

(3) Engineering and technical services, i.e., contractual services used to support the program office during the acquisition cycle by providing such services as systems engineering and technical direction (see 9.505-1(b)) to ensure the effective operation and maintenance of a weapon system or major system as defined in OMB Circular No.A-109 or to provide direct support of a weapon system that is essential to research, development, production, operation or maintenance of the system.

2.0 Procurement Responsibility:

2.1 In addition to the requirements above, Procurement Specialists shall, at their discretion, submit this to offerors whose anticipated proposals may not exceed the simplified acquisition threshold, but may present a situation where concern with regard to organizational conflict of interest that should be investigated.

2.2 If a suspected conflict of interest is identified, Procurement shall submit this form to the Office of General Counsel for review and disposition. The Office of General Counsel (OGC) will make a determination and return the signed form back to the Procurement Specialist. If OGC determines that a conflict exists that cannot be satisfactorily avoided, but determines that work must continue, OGC will submit this to DOE for review and approval.

2.3 This document shall become part of the Procurement file.

REVISION TABLE:

Revision Date Contact Description of Change 0 01/2007 Jim Kirlin Initial Release of OCI Conflict of Interest Form 1 07/12/2021 Elisabeth Dalle Combined FL-10 (01-07) and FL-11 (01-07) Updated to allow electronic completion & signatures

REVISION TABLE: