Attachment_7_OCIAnalysis-DisclosureForm_6_Jan_2016.pdf

W58RGZ-15-R-0166

Attachment 0007

OCI ANALYSIS/DISCLOSURE FORM

1. Contract Number

2. Program Title

3. Contractor Name and Address 4. Telephone Number and POC

5. Type of work to be performed under this solicitation:

See WLSS-C Basic Contract Performance Work Statement (PWS), Section C

Other related work requiring analysis and determination:

6. Contract Number, Program Title, and Govt. Technical POC

7. Brief Summary/Description of work performed under Block 6 action:

8. Relationship between requirements of Block 1 action and work performed under Block 6 action (If None, State Why):

9. Offeror/Contractor OCI Evaluation and Assessment (If either answer is yes, attach a copy of the PWS/Statement of Work (SOW) and complete Block 10):

(a) Does Actual OCI exist? ( ) Yes ( ) No

(b) Does Potential OCI exist? ( ) Yes ( ) No

10. Summary of actual/potential OCI, including actions planned to avoid, neutralize, or mitigate conflict or potential conflict:

11. Typed Name of Responsible Official 12. Signature 13. Date

14. Typed Name of Contracting Officer 15. Approval Signature 16. Date

16. Respective prime contract or subcontract OCI clause:

17. Provide the applicable contract PWS/SOW (as Block 17 Continuation Pages if necessary):

18. Provide (as Block 18 Continuation Pages) a copy of the PWS/SOW for each applicable task order performed or being performed by the offeror (ONLY for those tasks similar in nature to NSRWA requirements and not already defined in the respective contract PWS/SOW):

INSTRUCTIONS FOR COMPLETING OCI ANALYSIS/DISCLOSURE FORM

Blocks 1 through 5: Self-explanatory.

Block 6: Fill in the number and the short, official title by which the contract or subcontract requiring analysis and determination is formally known. Also provide the Government technical point of contact (including his/her current email address, office symbol, and telephone number).

This is for work the offeror (or any of its proposed team members and/or subcontractors) is currently performing (or in process of proposing on) and requires a comparison with that work described in Blocks 1-5.

NOTE: One OCI Analysis/Disclosure Form shall be submitted for EACH NSRWA or related contract or subcontract currently being performed.

Block 7: Provide a brief, but specific, narrative summary of the PWS/SOW (provided under Block 17) and work performed on the contract or subcontract listed in Block 6, including the period of performance and the value. Identify the specific applicable subparagraphs in the

PWS/SOW.

Block 8: Provide a brief, but specific, narrative summary of ANY relationship between the work to be performed under the action listed in Block 1 and the work performed (or currently being proposed on) under the action listed in Block 6. Be as specific as possible by citing the specific PWS/SOW paragraph where possible.

Block 9: Place an "X" in the appropriate ( ) for your responses.

Block 10: If you answer yes either to 9(a) or to 9(b), provide a summary of the actual or potential OCI and actions planned to avoid, neutralize, or mitigate conflict or potential conflict. Further, identify and address all concerns relative to the OCI clause under Block 16, as well as the contract OCI clause at H-___.

Blocks 11, 12, and 13: Provide the name of your company official with responsibility for and/or authority to discuss and commit the company on matters relating to OCI issues. That official should then sign and date each form.

Block 16: Provide a copy of the respective prime contract or subcontract OCI clause.

Block 17: Provide the applicable contract PWS/SOW (as Block 17 Continuation Pages if necessary).

Block 18: Provide (as Block 18 Continuation Pages) a copy of the PWS/SOW for each applicable task order (T/O) performed or being performed by the offeror (ONLY for those tasks similar in nature to NSRWA requirements and not already defined in the respective contract

PWS/SOW).