Conflicts Disclosure Policy

To ensure that the Rhode Island Department of Transportation (RIDOT) maintains the continued confidence and trust of the people of Rhode Island in carrying out its mission, prospective vendors must disclose any family (or other personal) relationships, associations or connections that the vendor, its affiliates, or employees, may currently have with any RIDOT employee. A Conflicts Disclosure Statement shall be submitted to RIDOT from the following:

• Owners;

• Directors;

• Principals:

• Officers, board members, or individuals with corporate authority;

• If the vendor is a partnership, the applicant’s partners;

• If the vendor is a limited liability company, its members and managers;

• Employees with decision-making authority, including executive directors, managers or individuals in a similar position with corporate authority; and

• Shareholders with a controlling interest.

Contract Number:

Contract Name:

Conflicts Disclosure Statement hereby certify as follows:

of and to the

RE:

I, I am employed as a best of my knowledge:

PLEASE CHECK THE APPROPRIATE BOX:

I have no family or personal relations currently employed either on a full-time or part-time basis at the Rhode Island Department of Transportation.

I do have family or personal relations currently employed at the Rhode Island Department of Transportation. Please list their name(s), title(s), and RIDOT Division(s) (if known):

Name Title RIDOT Division

If necessary, please add any additional names as attachments hereto.

FOR ILLUSTRATIVE PURPOSES, FAMILY RELATIONS SHALL INCLUDE, WHETHER BY

BLOOD, ADOPTION OR MARRIAGE, ANY OF THE FOLLOWING RELATIONSHIPS:

Father, Mother, Son, Daughter, Brother, Sister, Grandfather, Grandmother, Grandson, Granddaughter, Father-In-Law, Mother-In-Law, Brother-In-Law, Sister-In- Law, Son-In-Law, Daughter-In-Law, Stepfather, Stepmother, Stepson, Stepdaughter, Stepbrother, Stepsister, Half-Brother Or Half-Sister, Niece, Nephew, And Cousin

• If you are unsure whether a relationship, association, or connection you have may need to be disclosed, please consult with RIDOT’s Legal Office at (401) 222- 6510.

SIGNATURE DATE

By signing this form you: (1) certify that the information contained in this form is complete and accurate to the best of your knowledge; and (2) acknowledge your continuing obligation to complete and submit a new Disclosure form when there is any change in your family or personal relations during the course of this Contract.

This document is used for internal RIDOT purposes only in order to address and avoid any potential conflicts at the inception of the contract process and to avoid any impropriety or the appearance of impropriety during the contract process. Any disclosures made hereto will not prejudice prospective vendors from selection.