Atch_6_OCI_Disclosure_Form.docx

HF-TTL OCI Disclosure Form

FH-TTL Offeror (Prime Contractor or Proposed Subcontractor):

1. Name of Company:

2. Address:

3. Point of Contact and Telephone:

4. E-mail:

5. Size Status: Small ( ) Large ( )

6. List Affiliates:

Attachment 4 16 Aug 2016

OCI DISCLOSURE ATTACHMENT

INSTRUCTIONS FOR COMPLETING

NOTE: One Attachment to the OCI Disclosure Form shall be submitted for each USSOCOM contract or subcontract currently being performed. Place an "X" inside the appropriate parenthesis to indicate your responses.

Fill in the number and the short, official title by which the contract or subcontract requiring analysis and determination is formally known. This is work that has already been awarded, is being performed by your company, and requires a comparison with that work identified in Paragraph 6 of OCI Disclosure Form.

Please identify below the contract or subcontract held by your firm or affiliate and which may create an actual or potential OCI:

a. Contractor, Subcontractor or Affiliate’s Name:

b. Contract or Program Title:

c. Contracting Agency or Customer:

1. Your performance in the above contract is as a: Prime (__) or Subcontractor (__) Contract Number: _________________________ Task Order Number (if applicable):

2. If Subcontractor under 1, what is magnitude of work compared to overall contract value? Percentage (%): Dollar Value: Number of MYEs:

3. If you performed as a Sub, provide Prime Contractor’s name: ________________________________

4. Describe below the scope of the contract or subcontract in sufficient detail to understand the breadth of the work, the period of performance and the value, as it relates to:

Scope (continue on additional pages if more space is necessary):

5. Does the scope of work for this contract or subcontract create an actual or potential conflict of interest with the work you wish to perform under the HF-TTL contract? If so, describe the actual or potential conflict.