FINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST FY18-Procured Additional Steps~4.pdf

DCFS SPECIFIC STEP 8a

POTENTIAL CONFLICTS OF INTEREST FOR RELATED PARTY TRANSACTIONS

NOTE: For purposes of Steps 8 and Step 9 of this Contract, Key Management Staff is defined to include the top three highest paid staff funded under this Contract and the top persons managerially responsible for the services under this Contract.

Does any Key Management Staff receive compensation or payment in any form from another organization? Yes No

If so, name the employee and the other organization, the position held, the amount of annual compensation or type of payment, and the date when the employee began receiving such compensation or payment. Please include an attachment if necessary with requested information in a format substantially similar to the format below; please reference DCFS Specific Step 8a.

Name of Staff, Other Organization Work Hours, Compensation and Date of Hire for Other Organization

Does any Key Management Staff, Officer, Board Member, owner or majority stockholder (or members of their immediate families, i.e., spouse, father, mother, son, or daughter):

1 Hold an ownership interest in an organization that leases, subcontracts, or provides services or materials to you paid in whole or in part from funds generated by this Contract?; Yes No

2 Serve as an executive officer or board member of an organization that subcontracts or provides services or materials to you paid in whole or in part from funds generated by this Contract?;

Yes No

3 Serve as an employee of an organization that subcontracts or provides services or materials and part of his/her job duties include performing services related to the subcontract or the provision of services or materials to the organization for which he/she is a board member Yes No

If you answered yes to 1, 2, or 3 above, disclose the name of the individual(s), the organization(s), the nature of the lease(s), materials, services or subcontract(s). Please include an attachment if necessary with requested information in a format substantially similar to the format below; please reference DCFS Specific Step 8a.

Name of Staff, Board Member, Owner or

Stockholder

Organization Leasing, Contracting, Providing Services or

Materials

Nature of Lease, Services, Material or Subcontract

DCFS SPECIFIC STEP 9a

POTENTIAL CONFLICTS OF INTEREST

RELATING TO DEBARMENT & LEGAL PROCEEDINGS

(All vendors complete regardless of annual bid, offer, or contract value)

Please provide the name of the person or entity for which responses are provided:

1. Has any Key Management Staff or the Contracting Entity been debarred or suspended, or otherwise excluded or ineligible from participation in federal assistance programs or under other statutory or regulatory compliance requirements from contracting with any governmental entity?

Yes No

2. Have any Key Management Staff had adverse action taken in relation to a professional license?

Yes No

3. Has the Contracting Entity had any bankruptcies? Yes No

4. Has the Contracting Entity had any adverse civil judgments and administrative findings? Yes No

5. Has the Contracting Entity or any Key Management Staff had any criminal felony convictions? Yes No

If you answered “Yes”, please provide a detailed explanation that includes, but is not limited to the name, entity, and position title of each individual. Please include an attachment if necessary with requested information in a format substantially similar to the format below; please reference DCFS Specific Step 9a.

Name Position Organization Nature of Proceedings Date of Proceedings

SIGN THE DISCLOSURE

(All vendors must complete regardless of annual bid, offer, or contract value)

This disclosure is signed, and made under penalty of perjury, by an authorized officer or employee on behalf of the bidder offer or/Vendor pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code. This disclosure information is submitted on behalf of

Name of Disclosing Entity:

Signature: Date:

Printed Name:

Title:____________________________________________Phone Number________________________