Attachment_3_OCI_Disclosure_and_Analysis_Form.docx

OCI DISCLOSURE AND ANALYSIS FORM

1. Solicitation/Prime Contract:

2. Program Title

3. Contractor Name and Address

4. Telephone Number and POC

5. Type of work to be performed under this solicitation or, if after award, under this contract (mark all that apply)

Other NGA or IC efforts which may conflict with the work described in block 5, in accordance with FAR 9.5

6. Contract Number and Program Title

7. Brief Summary/Description of work performed under contract listed under Block 6:

8. Relationship between requirements of Block 1 action and work performed under Block 6 action (If None, State Why):

9. Offeror/Contractor OCI Evaluation and Assessment (If either answer is yes, attach a copy of the SOO and complete Block 10):

(a) Does Actual OCI exist? [ ] Yes [ ] No

(b) Does Potential OCI exist? [ ] Yes [ ] No

10. Descriptive Summary of actual/potential OCI, including actions planned to avoid, neutralize, or mitigate conflict or potential conflict:

11. Typed Name of Responsible Official

12. Signature

13. Date

14. Typed Name of Contracting Officer

15. Approval Signature

16. Date

UNCLASSIFIED

HRM II Attachment 3 –RFP HM047626R0018 Date: _______________

INSTRUCTIONS FOR COMPLETING OCI DISCLOSURE AND ANALYSIS FORM

Blocks 1 through 5: Self-explanatory.

Block 6: 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 described in Blocks 1-5.

NOTE: One OCI Disclosure and Analysis Form shall be submitted for EACH NGA contract or subcontract currently being performed.

Block 7: Provide a brief, but specific, narrative summary of the SOW/PWS and work performed on the contract or subcontract listed in Block 6, including the period of performance and the value. Continue on additional pages if more space is necessary.

Block 8: Provide a brief, but specific, narrative summary of ANY relationship between the work to be performed under the action listed in Block 1 and the previous work performed under the action listed in Block 6. Please be as specific as possible by citing the specific RFP/SOO paragraph where possible. Continue on additional pages if more space is necessary.

Block 9: Place an "X" inside the appropriate brackets to indicate your responses.

Block 10: If you answer yes either to 9(a) or to 9(b), provide a summary of the actual or potential OCI. Continue on additional pages if more space is necessary.

Blocks 11, 12, and 13: Provide the name of your company official with responsibility for and authority to discuss and commit the company on matters relating to OCI issues. That official should then sign and date each form.

Blocks 14 through 16: Self-explanatory.