L1 OCI_Disclosure_Form.pdf

OCI Disclosure Form

Offeror (Prime Contractor or Proposed Subcontractor)

Name of Company

Address

Point of Contact (POC)

POC Telephone

POC E-Mail

For the current solicitation, are you planning on bidding as a Prime Subcontractor Affiliate

List Affiliates (See definition at FAR

9.403.)

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 Missile Defense Agency (MDA) concerning Organizational Conflicts of Interest (OCI) with regard to __________________________ is dependent upon the information provided in this form and its attachments, and therefore may change if the Government receives further or different information.

Name and Title of Company Official Signature and Date

DA-78-F2

Page _____ of _____

Attachment _____ to OCI Disclosure Form

INSTRUCTIONS FOR COMPLETING

NOTE: One Attachment to the OCI Disclosure Form shall be submitted for each MDA, Ballistic Missile Defense System (BMDS) related, or MDA funded contract that has already been awarded and is either currently being performed or was previously performed. Fill in the number and the short official title by which the contract or subcontract requiring analysis and determination is formally known. Place an "X" inside the appropriate box to indicate your responses.

1. Identify below the contract or subcontract held by your firm or affiliate related to MDA BMD work in any way.

Contract or Program Title

Your Company is the Prime Subcontractor Affiliate

Contracting Agency or Customer Government Contracting Officer

POC (Name, Phone, E-Mail) Government Technical POC

(Name, Phone, E-Mail)

Contract Number

Task Order Number (if applicable)

Subcontract Number (if applicable)

BAA Number (if applicable)

SBIR/STTR Number (if applicable)

Period of Performance

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

Percentage (%)

Dollar Value ($)

Number of FTEs

3. If you are the subcontractor for the effort identified above, what is your magnitude of work compared to overall contract value (if known)?

Percentage (%)

Dollar Value ($)

Number of FTEs

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

Contractor Name

Address

Telephone

5. Check the boxes below that would apply to the scope of the contract or subcontract 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 non-public information (e.g. source-selection or proprietary information) (FAR 9.505-4)

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 below.

Does your company have 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?

6. Describe below the scope of your effort on the contract or subcontract in sufficient detail to understand the breadth of the work. Or provide a copy of your statement of work/performance work statement and highlight the scope that you as the Prime or Subcontractor perform.

7. Does your company have access to any Government systems containing non-public (e.g. source selection or proprietary) information?

Yes No

If the answer is yes, please explain

8. 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 this solicitation? If so, describe the actual or potential conflict.

9. Do you have a current mitigation plan with MDA or another agency involving this contract or subcontract?

Yes No

If the answer is yes, describe how the organizational conflict of interest was/is mitigated.

10.Have any former DoD employees who had access to information regarding this solicitation during their former DoD employment assisted your company on this acquisition?

Yes No

If the answer is yes, please identify the date the employee left DoD, the position they held when they had access to information regarding this solicitation, and the specific information they had access to.