Enclosure (3) OCI form.docx

PROCUREMENT AND PROPERTY MANAGEMENT DIVISION

BROOKHAVEN NATIONAL LABORATORY

Managed by Brookhaven Science Associates, LLC under contract to the U.S. Department of Energy

ACQUISITION MANAGEMENT SYSTEM FORM

Form No. AMS-Form-033

Revision No. 0.1

APPROVED BY:

L. McKnight /01/03/2021

PPM Manager/Date

Organizational Conflicts of Interest Disclosure

Organizational Conflict of Interest (OCI) means that because of other activities or relationships with other persons, a person is unable or potentially unable to render impartial assistance or advice to BSA, or the person's objectivity in performing the contract work is or might be otherwise impaired, or a person has an unfair competitive advantage.

(a) An offeror notified that it is the apparent successful offeror shall attach either (Check One):

(1) |_|A statement of any past (within the past twelve months), present, or currently planned, organizational, contractual, financial or other interests relating to the performance of the statement of work. Divide the statement into four parts – Organizational, Contractual, Financial, and Other. For contractual interests include the name, address, telephone number of the client or client(s), a description of the services rendered to the previous client(s), and the name of a responsible officer or employee of the offeror who is knowledgeable about the services rendered to each client, if, in the 12 months preceding the date of the statement, services were rendered to BSA or any other client (including a foreign government or person) respecting the same subject matter of the instant solicitation, or directly relating to such subject matter. The agency and contract number under which the services were rendered must also be included, if applicable. For financial interests, the statement must include the nature and extent of the interest and any entity or entities involved in the financial relationship. For these and any other interests enough such information must be provided to allow a meaningful evaluation of the potential effect of the interest on the performance of the statement of work. Or

(2) |_|A statement that no actual or potential conflict of interest or unfair competitive advantage exists with respect to the advisory and assistance services to be provided in connection with the instant contract or that any actual or potential conflict of interest or unfair competitive advantage that does or may exist with respect to the contract in question has been communicated as part of the statement required by (a)(1) of this provision.

(b) Failure of the offeror to provide the required statement may result in the offeror being determined ineligible for award. Misrepresentation or failure to report any fact may result in the assessment of penalties associated with false statements or such other provisions provided for by law or regulation.

I hereby certify (or as a representative of my organization, I hereby certify) that, to the best of my knowledge and belief, all relevant facts concerning past, present or currently planned interests or activities (organizational, contractual, financial, or otherwise) which relate to the proposed work and bear on whether I have (or the organizational has) a possible conflict of interest with respect to (1) being able to render impartial, technically sound, and objective assistance or advice, or (2) being given an unfair competitive advantage are fully disclosed on the attached page(s):

Signature: Date:

Name:

Title:

Organization:

Date Printed 10/3/2023 1 of 1 Date Approved 01/03/2021