OIAA_Conflict_of_Interest_Disclosure_Form_(1).pdf

1 Yes No

2 Yes No

3 Yes No

Nature of Income

CONFLICT OF INTEREST DISCLOSURE

SECTION 2: QUESTIONS

All persons, contractors, consultants, firms and suppliers doing business with the Ontario International Airport Authority

(OIAA) must complete and submit this Conflict of Interest Disclosure Form.

If this form is submitted along with the bid/proposal, it is essential to note that failure to comply with this requirement may cause your proposal to be declared non-responsive. Any questions regarding the information required to be disclosed in this form should be directed to OIAA’s General Legal Counsel, especially for any “yes” responses to questions in this form, which may also disqualify your firm from submitting an offer on the bid/proposal.

Company Name:

Preparer's Name:

RFP/RFQ/NIB #

Position/Title:

SECTION 1: INSTRUCTIONS

Do any employees, officers, consultants of OIAA, or any members of the OIAA Commission have any direct or indirect investments or interests in your firm or any real estate involving your firm worth at least $2,000? [Govt . Code, § 87103(a); 2 CCR § 18700(c)(3)(6)(A)] [Govt. Code, § 87103(b); 2 CCR §

18700 (c)(3)(6)(B)]

If no, leave blank. If yes, please list the names of those involved and the nature of the investment or real state interest:

Project Title:

(If applicable)(If applicable)

Is any employee, officer, or consultant of OIAA or any member of the OIAA Commission a director, officer, partner, trustee, employee, or hold any position of management in your firm, including any parent, subsidiary or other related business entity? [Govt. Code, § 87103(d); 2 CCR §

18700(c)(3)(6)(D)]

If no, leave blank. If yes, please list the names of those involved and the nature of the position:

Name Nature of Position

During the last twelve (12) months, has your firm provided or promised a source of income to any employee, officer, or consultant of OIAA or any member of the OIAA Commission, aggregating greater than $500? [Govt. Code, § 87103(c); 2 CCR § 18700(c)(3)(6)(C)]

If no, leave blank, If yes, please list the names of those involved and the nature of the source of income:

Name

Name Nature of Interest

Conflict of Interest Disclosure_Rev 7_ 1-2024 Page 1 of 3

4 Yes No

5 Yes No

6 Yes No

7 Yes No

8 Yes No

Date of ServicePosition

Nature of Interest

Does any employee, officer, or consultant of OIAA or any member of the OIAA Commission have any direct or indirect financial interest in your bid/proposal? [Govt. Code, § 1090]

If no, leave blank. If yes, please list the names of those who have a financial interest and the nature of the interest:

Have you or any member of your firm ever been an employee, officer, or consultant of OIAA or ever served as a member of the OIAA Commission within the last twelve (12) months?

If no, leave blank. If yes, please list the name, position, and dates of service:

Name

Name

Name Nature of Gift

Within the last twelve (12) months, have you or anyone at your firm (either directly, or through an intermediary or agent) given or promised any gift valued at least $590 to any employee, officer, or consultant of OIAA or any member of OIAA Commission, including their spouses or dependent children? [2 CCR § 18940.2(a); 2 CCR § 18700(c)(3)(6)(E)]

If no, leave blank. If yes, please list the names of those involved and the nature of the gift:

Name Name

Name Relationship

Are you or any managers, partners, or officers of your firm related by blood or marriage/domestic partnership to any employee, officer, or consultant of OIAA or member of the OIAA Commission that is considering your proposal?

If no, leave blank. If yes, please list the names and nature of the relationship:

Does this agreement include work performed by subcontractors?

If no, leave blank. If yes, please list the subcontractors/company below:

Conflict of Interest Disclosure_Rev 7_ 1-2024 Page 2 of 3

9 Yes No

(A) Yes No

(B)

Yes No

Yes No

Yes No

(C) Yes No

I (print full name) hereby declare that I am the (position or title)

Statement on behalf of this entity. I hereby state that this OIAA Conflict of Interest Disclosure form dated

NOTICE: A material false statement, omission, or fraudulent inducement made in connection with this OIAA Conflict of

Interest form is sufficient cause for rejection of the contract/proposal /service or revocation of a prior contract award.

Signature of Person Certifying for Proposer Date is correct and current as submitted.

DECLARATION

I acknowledge that any false, deceptive, or fraudulent statements on this Validation Statement will result in rejection of my contract/proposal/service.

of (firm name) and that I am duly authorized to execute this Validation

Is the contributor a participant in the proposal being made to OIAA for decision, by doing any of the following:

Is the contributor an agent of a party or a participant in the proposal to be decided by OIAA for decision? (A person is an agent if they represent you in connection with the proposal before OIAA.)

Communicating with any member of OIAA Commission for the purpose of influencing their decision on the proposal?

Further, if the answer to Question No. 9 above is "Yes" please answer each of the following below. [Govt.Code, § 84308; 2 Cal. Code Regs., §§ 18438.3, 18438.4]

Name(s) /Position(s)

Is the contributor a party to the proposal being made to OIAA for decision?

SECTION 3: VALIDATION STATEMENT

This Validation Statement must be completed and signed by at least one General Partner, Owner, Principal, or Officer authorized to legally commit the proposer.

Testifying or making any oral statements before the OIAA Commission for the purpose of influencing the decision on the proposal?

Communicating with any employee, officer, or consultant of OIAA, or is the contributor's agent lobbying, testifying, or communicating with anyone at

OIAA or any member of OIAA Commission, for the purpose of Influencing the decision on the proposal ?

Dollar ValueDate(s)

In the last twelve (12) months, have you or any employee of your firm (including managers, partners, directors and/or officers), either directly or indirectly through an intermediary or agent, ever given or promised a campaign contribution, aggregating greater than $250 to any employee, officer, or consultant of OIAA or any member of the OIAA Commission (including contributions to a political committee created by or on behalf of a member/candidate)? [Govt. Code, § 84308(b)]

If no, leave blank. If yes, please list the name, position, and dates of service:

Conflict of Interest Disclosure_Rev 7_ 1-2024 Page 3 of 3