Attachment B - Conflict of Interest Statement Form.pdf
PDF 205 KB Posted
- Solicitation number
- NSF-Topic3-FY26-XLabsPhysicalAI
- Issued by
-
National Science Foundation
About this file
This is a Conflict of Interest Statement form for the NSF X-Labs Initiative (Solicitation/Contract Number NSF-OTASO-FY26-XLabsInitiative), required as part of proposal submissions to the National Science Foundation.
The form requires offerors to disclose organizational conflicts of interest (OCIs) governed by FAR Subpart 9.5, which are categorized into three types: Impaired Objectivity (where a contractor assesses or evaluates itself, an affiliate, or competitor); Biased Ground Rules (where a contractor helped establish terms such as statements of work or specifications); and Unequal Access to Information (where a contractor obtains nonpublic or source selection sensitive information providing competitive advantage). By signing, offerors acknowledge responsibility to immediately disclose any financial interests, employment relationships, personal relationships, prior involvement, or other circumstances that could create or appear to create an OCI for the lead organization, its employees, and any proposed subcontractors or consultants. The form includes checkboxes to indicate whether the team is aware of conflicts and requires detailed explanations in designated sections for: actual, apparent, or potential financial interests creating conflicts; relevant prior work on contracts or Other Transaction agreements that could create conflicts; and mitigation plans describing how the organization will avoid, neutralize, or mitigate any identified conflicts. The form concludes with a certification section requiring signature, date, printed name, and contact information from an authorized representative confirming the accuracy and completeness of disclosed information and commitment to prompt reporting of any changes.
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Conflict of Interest Statement
Solicitation/Contract Number/Project: NSF X-Labs; NSF-OTASO-FY26-XLabsInitative
COIs are governed by the FAR Subpart 9.5. Organizational COIs (OCIs) are generally separated into three categories:
• Impaired Objectivity, which may arise where an Other Transaction (OT) contractor's work under one OT or contract involves assessing or evaluating itself, an affiliate, or a competitor, creating an economic incentive to provide biased advice under an OT transaction;
• Biased Ground Rules, which may occur when, as part of its work under one contract or transaction, the OT entity has helped set the ground rules, such as writing the statement of work or developing specifications, for an OT;
• Unequal Access to Information, which may occur when an OT entity obtains access to nonpublic, proprietary, or source selection sensitive government information as part of its performance under another contract or transaction, which gives it an advantage in a later competition for an OT.
By signing this form, the offeror acknowledges that:
We will immediately disclose any financial interest, employment or business relationship, personal relationship, prior involvement, or other circumstance that could create - or appear to create – an OCI.
This requirement applies to the lead organization, its employees, and any subcontractors/consultants proposed to perform work.
If, at any time, we identify an actual or potential OCI (using RFO FAR Subpart 9.5 as a framework) that has not been adequately disclosed and resolved (or waived in writing by NSF), the contractor must promptly provide full written disclosure to NSF’s Agreements Officer Representative (AOR). The disclosure must describe the conflict and the actions taken or proposed to resolve it.
Conflict disclosure
Check one:
☐ Our team is not aware of any actual, apparent, or potential organizational conflict of interest related to this proposal.
☐ Our team has disclosed a matter that may create an actual, apparent, or potential organizational conflict of interest below or in an attachment.
Explanation, if applicable:
Describe any actual, apparent, or potential financial interests of the lead organization that could create conflicts with the work proposed. This requirement applies to the lead organization, its employees, and any subcontractors/consultants proposed to perform work.
https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.acquisition.gov%2Ffar%2Fsubpart-9.5&data=05%7C02%7Cxlabs%40nsf.gov%7C27bbd5950ce14149f9d708dedde347e3%7C4939bd9435634244904d6e68ffc9b8cf%7C0%7C0%7C639192165583607059%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C80000%7C%7C%7C&sdata=AMsrLQAj6DG3J2vPrJLtGM7yfUV7mclmE2rB5Xv2U%2BU%3D&reserved=0
Relevant Prior Work, if applicable:
Describe any work performed on a previous or current contract or OT Agreement that could create conflicts with the work proposed. This requirement applies to the lead organization, its employees, and any subcontractors/consultants proposed to perform work.
Mitigation Plan, if applicable:
Describe how the lead organization will avoid, neutralize, or mitigate any potential or actual conflicts.
Certification and signature
I have read and understand this agreement. The information above is complete and accurate to the best of my knowledge, and I will promptly report any change.
Signature:
Date:
Printed Name:
Phone/Email:
| Our team is not aware of any actual apparent or potential organizational conflict of interest related: Off |
| Our team has disclosed a matter that may create an actual apparent or potential organizational: Off |
| Signature: |
| Date: |
| Printed Name: |
| PhoneEmail: |
| Explaination: |
| Relevant Prior Work: |
| Mitigation Plan: |
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