Attachment_J-2_Conflict_of_Interest_Reviewer.docx

Conflict of Interest Certification for Direct Component Outside Reviewers I, the undersigned Outside Reviewer of an application to the RESTORE Act Direct Component program, hereby certify that if, at any time during the award process, I have a conflict of interest or my particular circumstances are likely to create the appearance of a conflict of interest with respect to the application submitted by ______________________[insert applicant],I immediately shall inform the Treasury official who oversees review assignments for non-federal personnel (“Treasury Supervisor”). I also shall inform the Treasury Supervisor if, at any time during the evaluation process, I cannot objectively evaluate this application for any reason. For purposes of this certification, I recognize that I shall be considered to have a conflict of interest or an appearance of a conflict of interest with respect to this application if I, my spouse, parent, dependent child or any member of my household:

1. Serves, or in the last year has served, as an officer, director, trustee, partner, agent, attorney, consultant, contractor, or employee of this applicant or any contractor or sub-recipient specifically mentioned in this application, or receives the primary source of his or her income from this applicant or any contractor or sub-recipient specifically mentioned in this application.

2. Is negotiating, or has an arrangement concerning, prospective employment or a contracting relationship with this applicant or any contractor or sub-recipient specifically mentioned in this application.

3. Has a financial interest in the Treasury’s action with respect to the application which would constitute a “financial interest” within the meaning of 18 U.S.C. § 208. (Such “financial interests” arise from, but are not limited to, receipt of salaries or fees paid by, and interests in equity or other securities issued by, the applicant or any contractor or sub-recipient specifically mentioned in this application.)

4. Serves, or has served, during the preparation of the application or the pendency of the award process in which the application is being considered, as an officer, director, trustee, partner, agent, attorney, consultant, contractor or employee of or receives the primary source of his or her income from an entity that either (1) has provided assistance in the preparation of the application or otherwise facilitated the submission of the application or (2) has a financial interest in Treasury's action with respect to the application.

I recognize that this certification is a continuing representation, and that it is in effect at all times until I have completed all of the work to be performed by me in connection with this application for the Treasury RESTORE Act Direct Component program. By signing below, I attest that:

· My review of the application does not present a real, potential, or apparent conflict of interest, as conflict of interest is defined in this certification; and

· If I subsequently become aware of any real, potential, or apparent conflict of interest, I immediately will advise my Treasury Supervisor. I will then refrain from further involvement in the review of this application unless my Treasury Supervisor determines no conflict exists.

Printed name of Outside Reviewer

Date signed

Signature of Outside Reviewer

RFP #A15080 Attachment J -2 Conflict of Interest, Reviewer