Attachment_C_OCI.doc

Attachment C

PAGE

OCI REPRESENTATION/DISCLOSURE STATEMENT AND QUESTIONNAIRE

Complete Either the Representation or the Disclosure

OCI REPRESENTATION STATEMENT

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, 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 unfair competitive advantage.

Signature:

Date: _______________ Name :

Organization: _________ Title :

OCI DISCLOSURE STATEMENT

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, 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 and unfair competitive advantage--are fully disclosed on the attached page(s) and formatted to show:

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

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

o A brief description of relationship;

o A period of relationship;

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

Signature:

Date:

Name : __________ Organization:

Title : ___________

Name of Person or Organization:

OCI QUESTIONNAIRE

1.

Will you (or your organization) be involved in the performance of any portion of proposed work?

No.

Yes. The portion of the proposed work; the proposed hours and dollar value; and the type of involvement are fully disclosed on the attached pages.

2.

What is (are) the major type(s) of business conducted by you (or your organization)? Please reply on the attached pages.

3.

Do you (or your organization) have any affiliates?

No.

Yes. The name and a description of the major type(s) of business that each affiliate conducts are disclosed on the attached pages.

4.

Will any of the following be involved in performing the proposed work: (a) any entities owned or represented by you (or your organization); (b) your organization's Chief Executive; any of its directors; or (c) any affiliates?

No.

Yes. A full disclosure and discussion is given in the attached pages.

5.

Are you (or your organization) an energy concern?

No.

Yes. A full disclosure and discussion is given on the attached pages.

6.

Do you (or your organization) have a direct or indirect relationship (financial, organizational, contractual or otherwise) with any business entity which could be affected in any way by the proposed work?

No.

Yes. List the business entity (ies) showing the nature of your relationship and how it would be affected by the proposed work.

7.

What percentage of your total income for the current and preceding fiscal years resulted from arrangements with any of the entities identified in Question 6 above?

For the current fiscal year--from / / to / / .

For the preceding fiscal year--from / / to / / .

8.

Do you (or your organization) currently have or have you had during the last six years any arrangements (for example, contracts and cooperative agreements) awarded, administered, or funded--wholly or partly--by the Commission or any other Federal Agency which relate to the proposed Statement of Work?

No.

Yes. A full disclosure and discussion is given on the attached pages.

9.

Do you (or your organization) have or have you ever had any contracts, agreements, special clauses, or other arrangements which prohibit you (or your organization) from proposing work to be performed in this solicitation or any portion thereof?

No.

Yes. A full disclosure and discussion is given on the attached pages.

10.

Do you (or your organization) have any involvement with or interest (direct or indirect) in technologies which are or may be subjects of the contract, or which may be substitutable for such technologies?

No.

Yes. A full disclosure and discussion is given on the attached pages.

11.

Could you (or your organization) in either your private or Government business pursuits utilize information acquired in the performance of the proposed work; such as:

(a) Data generated under the contract?

(b) Information concerning Commission plans and programs?

(c) Confidential and proprietary data of others?

No.

Yes. A full disclosure and discussion is given on the attached pages.

Name of Person or Organization:

12.

Under the proposed work, will you (or your organization) evaluate or inspect you own services or products, or the services or products of any other entity that has a relationship (e.g., client, organizational, financial, or other) with you (or your organization). This could include evaluating or inspecting a competitor's goods and services.

No.

Yes. A full disclosure and discussion is given on the attached pages.

13.

To avoid what you perceive as a possible organizational conflict of interest, do you (or your organization) propose to: exclude portions of the proposed work; employ special clauses; or take other measures?

No.

Yes. A full discussion is given on the attached pages.

No possibility of an organizational conflict of interest is perceived. This answer is briefly justified on the attached pages.

I hereby certify that I have authority to represent my organization, if applicable, and that--to the best of my knowledge and belief--the facts and representations presented on the three pages of this questionnaire and on the pages of the attachment to it are accurate and complete.

Signature:

Date:

Name :

Organization:

Title

�An unfair competitive advantage does not include the normal flow of benefits from the performance of the contract.