Attachment L-05_TEAMS ITMA - OCI Disclosure Form.pdf

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Attachment L-05 OCI Disclosure Form

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TEAMS OCI Disclosure Form

TEAMS 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:

7. Please indicate with an “X” which capability area under TEAMS you wish to compete for and whether you are interested in a prime contract or subcontract:

Capability Areas

Role

Prime Subcontractor

Quality, Safety &

Mission Assurance

Quality & Mission Assurance

Safety

2 Engineering

BMD Predictive Engineering

International Engineering

Specialty Engineering

BMD Systems Engineering

BMD Weapons Engineering

C3BM Engineering

3 Test Test Provisioning Support

Test, Exercise, and War-game Support

Information

Technology and

Cybersecurity

IT Management & Analysis

Cybersecurity & Risk Management

BMDS Cybersecurity Management / Computer

Network Defense

5 Acquisition Acquisition and Program Management Support;

Acquisition Executive Support; and ISG

6 Business Operations

Strategic Financial Planning; Budget Execution /

Funds Control; Cost Estimating; Accounting;

EVMS; Financial Systems Support Integration

Security and

Intelligence

Cybersecurity Engineering

Intelligence

Counter Intelligence

Security / Program Protection; Declassification

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Capability Areas

Role

Prime Subcontractor

Human Resources and Training

Human Resources Support; Training and

Development

9 Administration

Office Administration

Strategic Planning

Visual Information Production Center

Protocol and Public Information Support

10 Facilities

Facilities, Logistics & Space Management

Environmental Management

Facilities Life Cycle Management

11 Warfighter Warfighter Strategic Integration; Operations

Support

12 Logistics Lifecycle Logistics Management

13 International International Affairs; FMS

Advisory and

Analytical Support Agency Advisory and Analytical Support

Submit one completed Attachment to this OCI Disclosure Form per Contract.

This form and its attachments are complete and accurate to the best of my knowledge. I understand that any written guidance I receive from MDA concerning Organizational Conflicts of Interest with regards to TEAMS is dependent upon this information, and therefore may change if the Government receives further or different information.

Name and Title of Company Official Signature and date

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ATTACHMENT ____

TO

OCI DISCLOSURE FORM

INSTRUCTIONS FOR COMPLETING

NOTE: One Attachment to the OCI 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 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:

(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. If Subcontractor under 1, what is magnitude of work compared to overall contract value?

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

3. For both Prime and Subcontractor, what is the magnitude of this work compared to the contractor’s overall business base?

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

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

Contractor Name: ____________________________________________________________

Address: ___________________________________________________________________

Phone: _____________________________________________________________________

5. 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)

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(___) Providing products, hardware or software to MDA or another contractor to use within the BMDS. If providing products, explain whether the products are vendor-type or developed products.

(___) Any significant business relationship with any MDA development contractors.

Please describe the relationship, the nature of the contract and the percentage of your business comprised by this contract or business relationship.

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

Scope:

6. 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 TEAMS? If so, describe the actual or potential conflict. Keep impaired objectivity OCIs in mind when considering possible conflicts.

7. 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.

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