Att L7 OCI Disclosure Form 6 Feb 20.docx

Attachment L7 OCI Disclosure Form Page __of

OCI Disclosure Form

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 TEAMS Next Contract you wish to compete for and whether you are interested in a prime contract or subcontract:

MDS Engineering

Advisory, Agency, Analytical Support

Specialized Engineering Analyses

Counterintelligence

Security Operations

Cyber Compliance and Risk Management

Cybersecurity and IT Management

Warfighter Integration

Test Support

Facilities Life-cycle Management

Program Planning & Acquisition

Facilities, Logistics, Environmental

Quality and Mission Assurance

Safety

Agency Operations

Contracting Compliance Cost/Price Operations

Administration

Public Affairs

February 23, 2015

January 9, 2020

HQ0858-20-R-0001

Attachment L-7 OCI Disclosure Form Page __of

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 Next 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

Attachment L-7 OCI Disclosure Form Page of

ATTACHMENT TO

OCI DISCLOSURE FORM

INSTRUCTIONS FOR COMPLETING

NOTE: One Attachment to the OCI Disclosure Form shall be submitted for each MDA funded contract, subcontract, or other agency effort 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, subcontract, or other agency activity 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 performed by your firm or affiliate 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:

HQ0147-17-R-0027

Attachment L-7 OCI Disclosure Form

Page of ( ) Development, production, or sustainment of any portion of the Missile Defense System (MDS) If providing products, explain whether the products are vendor-type or developed products.

( ) Technology development in support of future MDS capabilities ( ) Testing of MDS capabilities ( ) Development or production of targets or countermeasures in support of MDS testing ( ) 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 Next? 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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