Atch L1 OCI Disclosure Form

ATTACHMENT L-1

OCI ANALYSIS/DISCLOSURE FORM

INSTRUCTIONS FOR COMPLETING

NOTE: One OCI Analysis/Disclosure Form shall be submitted for EACH BMD, BMD-related or MDA-funded 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 the OCI Analysis/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: _________________________________________

(Example: Army, NASA, Air Force, etc.)

1. Your performance in the above contract is as a: Prime (____) Subcontractor (____)

Contract Number: ________________________________________________________

Task Order Number: ______________________________________________________

Subcontract Number: ____________________________________________________

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

Percentage (%): _____ Dollar Value: _______ Number of MYEs: ______

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

Contractor Name: ____________________________________________________________

Address: ___________________________________________________________________

Phone: _____________________________________________________________________

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:

(___) Providing Systems 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)

Page __ of __

(Continue on additional pages if more space is necessary.)

Scope:

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 Clear/Cape Cod UEWR program? If so, describe the actual or potential conflict. Keep impaired objectivity OCIs in mind when considering possible conflicts.

6. Do you have a current mitigation plan with MDA or another agency involving this contract or subcontract? (Y/N) _____. If yes, describe how the organizational conflict of interest was/is mitigated.

Name and Title of Company Official Signature and date