L5_OCI_Disclosure_Form_120216.pdf

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Missile Defense Agency Information Technology Collaboration Services

(MICS)

H95001-10-R-0001

Organizational Conflict of Interest (OCI) Disclosure Form

Date: 17 Feb 2012

Section L, Attachment 5: OCI Disclosure Form H95001-10-R-0001 Offeror (Prime Contractor or proposed Teammate/Subcontractor):

1.

Name of Company:

2.

Address:

3.

Point of Contact:

Phone:

4.

E-Mail:

5.

Size Status per NAICS 541513: Small Large This form and its attachments are complete and accurate to the best of my knowledge. I understand that any guidance, verbal or written, I receive from MDA concerning Organizational Conflict of Interest with regards to the subject contract is dependent upon this information and therefore is subject to change if the Government receives further or different information.

Name and Title Signature Date of Company Official Section L – Attachment 5 Missile Defense Agency Information Technology Collaboration Services

(MICS)

Organizational Conflict of Interest (OCI) Section L, Attachment 5: OCI Disclosure Form H95001-10-R-0001

INSTRUCTIONS FOR COMPLETING

NOTE: One Attachment to the OCI Disclosure Form shall be submitted for EACH MDA-funded contract or subcontract or other potentially conflicting contract currently being performed. Check each box and fill in the blanks to indicate your responses.

Fill in the contract 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 and is being performed by your company.

Identify 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 Subcontractor BMDS Contract Infrastructure/Services Contract A&AS/SETA Contract Contract Number:

Task Order Number:

Subcontract Number:

2. What is the magnitude of this work compared to the Contractor’s overall business base?

Percentage Annual Dollar Value # of FTE

3. If you performed as a Subcontractor, provide Prime Contractor’s information:

a.

Contractor Name:

b.

Address:

c.

Phone:

Section L, Attachment 5: OCI Disclosure Form H95001-10-R-0001 8.2.1.3158.1.475346.466429

4. Check the appropriate box(s) and 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 Providing System Engineering and Technical Direction (FAR 9.505-1) Preparing Specifications or Work Statements (FAR 9.505-2) Providing Technical Evaluation of Offers for Products or Services (FAR 9.505-3) Obtaining Access to Proprietary Information (FAR 9.505-4) Providing Advisory and Assistance Services (A&AS) or Systems Engineering and Technical Assistance (SETA) services to the MDA Providing products, services, hardware, software or strategic planning recommendations to MDA or another contractor, for use within MDA. If providing products, explain whether the products are vendor-type or developed products.

Significant business relationship with any MDA BMDS development, fielding, or sustainment Contractors. Please describe the relationship, the nature of the contract, and the percentage of your business comprised by this contract or business relationship:

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 on the subject contract? (Reference: FAR 2.101 and 9.5; Contract Section H-09; Section J Attachment 4 – MDA OCI Policy) If so, describe the actual or potential conflict. Consider bias/impaired objectivity type OCIs when assessing potential conflicts.

6. If you have a current mitigation plan with MDA or another agency involving this contract or subcontract describe how the organization conflicts of interest was/is mitigated.

Section L, Attachment 5: OCI Disclosure Form H95001-10-R-0001