conflict_of_interest_statement_(Template).pdf

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Conflict of Interest Statement The information herein is FOR OFFICIAL USE ONLY (FOUO) information which must be protected under the Freedom of Information Act (5 U.S.C 552) and/or the Privacy Act of 1974 (5 U.S.C. 552a). Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in disciplinary action, criminal and/or civil penalties.

Page of Updated: 17 Feb 16 Please review the list - with the Procuring Contracting Officer (PCO) - of prime contractors and their subcontractors who are offering proposals in response to the Request for Proposal for the acquisition identified above. After reviewing the list, check the appropriate box below and complete the signature block.

I certify that neither I nor my spouse or minor children, to the best of my knowledge, possess a disqualifying financial interest in any offeror, subcontractor, or supplier (including parent and subsidiary corporations) that is proposing on the acquisition identified above now being considered by the Source Selection Evaluation Board (SSEB), of which I am a member or an advisor. Financial interest includes a present or planned employment relationship. Should my aggregate financial interests (including the interests of my spouse and minor children) in the companies involved in this source selection increase to more than $15,000 for publicly traded stocks or more than $50,000 for sector mutual funds, I will immediately disqualify myself from further participation and reveal such interests to the SSEB Chairperson and the PCO.

I do/may possess a disqualifying financial interest in an offeror, subcontractor, or supplier that is proposing on or is in a way involved in the acquisition identified above now being considered by the Source Selection Evaluation Board (SSEB), of which I am a member or advisor. (If you check this box, please provide a description of your financial interests on the reverse side of this form.) I further acknowledge my obligation to disclose any friendships, family or social relationships, past employment relationships, or any other type of relationship, such as housing or transportation arrangements, when a reasonable person with knowledge of the relevant facts would question my impartiality in this matter. (Please make any disclosures on the reverse of this form.)

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