U.S. Department of Commerce

Attachment 6

Conflict of Interest Certification

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GENERAL INFORMATION

NAME OF PROJECT: _________________________________________________

TEAM MEMBER/ADVISOR: ____________________________________________

CERTIFICATION STATEMENT:

I certify that I am not aware of any matter which might limit my ability to participate in this acquisition in an objective and unbiased manner, or which might place me in a position of conflict, real or apparent, between my responsibilities as a member of this panel or other interests.

In making this certification, I have considered all my stocks, bonds, other financial interests, and employment interests (past, present, or under consideration) and, to the extent known by me, all the financial interests and employment arrangements of my spouse, my minor children and other members of my immediate household.

If, after the date of this certification, any person, firm, or other organization with which, to my knowledge, I (including my spouse, minor children, and other members of my immediate household) have a financial interest, or with which I have (or had) an employment arrangement, submits a proposal or otherwise becomes involved in the acquisition, I will notify the Contracting Officer of this apparent conflict of interest. Until advised to the contrary, I will not participate further in any way (by rendering advice, making recommendations, voting or otherwise) in the work of this panel.


_______________________________________
NAME

___________________________________________________
SIGNATUREDATE


If, after the date of this certification, any person, firm, or other organization with which, to my knowledge, I (including my spouse, minor children, and other members of my immediate household) have a financial interest, or with which I have (or had) an employment arrangement, submits a proposal or otherwise becomes involved in the acquisition, I will notify the Board Chairperson and the Contracting Officer of this apparent conflict of interest. Until advised to the contrary, I will not participate further in any way (by rendering advice, making recommendations, voting or otherwise) in the work of this Board.



Source: U.S. Census Bureau
Acquisition Division

Last Revised: October 15, 2012