COI & Confidentiality StatementsLocal Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
EXHIBIT 10-T CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT
RFP/RFQ PROCUREMENT NUMBERS: CLQ082219
PROJECT NAME:
SilverRock Park Venue Construction Management Services 2016-08
APPLICABILITY: Applicable to local agency consultant procurements which will contain Federal
or State funds in the consultant contract.
❑ I am an employee of the local agency that is involved in this procurement.
❑ I am an employee of a consultant under contract to the local agency that is responsible for this
procurement but I am not in a management position with the local agency.
❑ I have a personal, financial, or business interest in past employment activity or a personal
relationship regarding the firms (including subconsultants) that are the subject of this
evaluation. A brief description is provided on the back of this form.
❑ I certify that I have no current contractual relationship with any of the firms (including
subconsultants) that are the subject of this evaluation.
❑ I certify that I have no personal or financial interest and no present or past employment activity
or personal relationship or prior contractual relationship which would be incompatible with my
participation in this solicitation process and I am fully able to give full, fair and impartial
consideration to all proposals/bids as an appointee to the related evaluation.
111 certify that I have read 23 CFR 172.7(b)(4) below and I agree not to participate in selection,
or in the award or administration of a contract supported by Federal funds if a conflict of
interest, real or apparent, would be involved.
23 CFR 172.7(b)(4)
(4) Conflicts of interest. (i) A contracting agency shall maintain a written code of standards of conduct governing the
performance of their employees engaged in the award and administration of engineering and design related services contracts
under this part and governing the conduct and roles of consultants in the performance of services under such contracts to prevent,
identify, and mitigate conflicts of interest in accordance with 2 CFR 200.112, 23 CFR 1.33 and the provisions of this paragraph
(b)(4).
(ii) No employee, officer, or agent of the contracting agency shall participate in selection, or in the award or
administration of a contract supported by Federal -aid funds if a conflict of interest, real or apparent, would be involved.
Such a conflict arises when there is a financial or other interest in the consultant selected for award by:
(A) The employee, officer, or agent;
(B) Any member of his or her immediate family;
(C) His or her partner; or
(D) An organization that employs or is about to employ any of the above.
LPP 18-01 Page 1 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
(iii) The contracting agency's officers, employees, or agents shall neither solicit nor accept gratuities, favors, or
anything of monetary value from consultants, potential consultants, or parties to subagreements. A contracting agency
may establish dollar thresholds where the financial interest is not substantial or the gift is an unsolicited item of
nominal value.
(iv) A contracting agency may provide additional prohibitions relative to real, apparent, or potential conflicts of
interest.
(v) To the extent permitted by State or local law or regulations, the standards of conduct required by this paragraph
shall provide for penalties, sanctions, or other disciplinary actions for violations of such standards by the contracting
agency's officers, employees, or agents, or by consultants or their agents.
efun-'Vy"understand
A contracting agency shall promptly disclose in writing any potential conflict of interest to FHWA.
and agree to immediately disqualify myself as soon as I am aware of a
conflict of interest that may compromise my fair and impartial consideration of the
proposals/bids.
LEI certify that I will hold in the strictest confidence all bids, proposals, correspondence,
memoranda, working papers, or any other media which has any bearing on, or disclose any
aspect of, any respondent or potential respondent to the RFP/RFQ above. I will not discuss the
evaluation process with anyone not involved in the evaluation process until its completion.
P- I fuI ly understand that it is unlawful for a person to utilize any organization name or auxiliary
organization information, which is not a matter of public record, for personal gain.
C-�f� I fully understand that any violation of the above is a basis for disciplinary action, up to and
including termination or referral to the appropriate authorities for further investigation.
I am aware that the following firms and subconsultants/subcontractors have submitted
proposals in response to the above referenced solicitation:
List firms including subconsultants/subcontractors:
1.
Dudek
2.
GC Construction Inspection Management
3.
HR Green Pacific
4.
NV5
5.
Project Dimensions
6.
Z&K Consultants
LPP 18-01 Page 2 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
Date: Signed: %
Name:
Title: ,� N�yGd •'��.,lr�G Z
Dept./Local Agency: Cl
Employer:
CONTRACT ADMINISTRATOR'S REVIEW
I have reviewed the foregoing "Conflict of Interest and Confidentiality Statement" and have
determined, according to the information provided, that this individual:
Date:
does not have a conflict of interest and can participate in the "Selection
Panel"
Q does have a conflict of interest and cannot participate in the "Selection Panel"
Signed:
Name:
Title:
Dept./Local Agency:
Employer:
Distribution: Original — Local Agency Consultant File
LPP 18-01 Page 3 of 3
January 2019
� I
:� .. �.
-� 1. ■ � - i •� ,�
i�
3• ti
1h
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
EXHIBIT 10-T CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT
RFP/RFQ PROCUREMENT NUMBERS: CLQ 82219
PROJECT NAME:
SilverRock Park Venue Construction Management Services, 2016-08
APPLICABILITY: Applicable to local agency consultant procurements which will contain Federal
or State funds in the consultant contract.
Cam an employee of the local agency that is involved in this procurement.
❑ I am an employee of a consultant under contract to the local agency that is responsible for this
procurement but I am not in a management position with the local agency.
❑ I have a personal, financial, or business interest in past employment activity or a personal
relationship regarding the firms (including subconsultants) that are the subject of this
evaluation. A brief description is provided on the back of this form.
6?fcertify that I have no current contractual relationship with any of the firms (including
subconsultants) that are the subject of this evaluation.
&Kcertify that I have no personal or financial interest and no present or past employment activity
or personal relationship or prior contractual relationship which would be incompatible with my
participation in this solicitation process and I am fully able to give full, fair and impartial
consideration to all proposalsibids as an appointee to the related evaluation.
2-1"Certify that I have read 23 CFR 172.7(b)(4) below and I agree not to participate in selection,
or in the award or administration of a contract supported by Federal funds if a conflict of
interest, real or apparent, would be involved.
23 CFR 172.7(b)(4) .
(4) Conflicts of interest. (i) A contracting agency shall maintain a written code of standards of conduct governing the
performance of their employees engaged in the award and administration of engineering and design related services contracts
under this part and governing the conduct and roles of consultants in the performance of services under such contracts to prevent,
identify, and mitigate conflicts of interest in accordance with 2 CFR 200.112, 23 CFR 1.33 and the provisions of this paragraph
(b)(4).
(ii) No employee, officer, or agent of the contracting agency shall participate in selection, or in the award or
administration of a contract supported by Federal -aid funds if a conflict of interest, real or apparent, would be involved.
Such a conflict arises when there is a financial or other interest in the consultant selected for award by:
(A) The employee, officer, or agent;
(B) Any member of his or her immediate family;
(C) His or her partner; or
(D) An organization that employs or is about to employ any of the above.
LPP 18-01 Page 1 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
(iii) The contracting agency's officers, employees, or agents shall neither solicit nor accept gratuities, favors, or
anything of monetary value from consultants, potential consultants, or parties to subagreements. A contracting agency
may establish dollar thresholds where the financial interest is not substantial or the gift is an unsolicited item of
nominal value.
(iv) A contracting agency may provide additional prohibitions relative to real, apparent, or potential conflicts of
interest.
(v) To the extent permitted by State or local law or regulations, the standards of conduct required by this paragraph
shall provide for penalties, sanctions, or other disciplinary actions for violations of such standards by the contracting
agency's officers, employees, or agents, or by consultants or their agents.
(vi) A contracting agency shall promptly disclose in writing any potential conflict of interest to FHWA.
L" I fully understand and agree to immediately disqualify myself as soon as I am aware of a
conflict of interest that may compromise my fair and impartial consideration of the
proposals/bids.
2' I certify that I will hold in the strictest confidence all bids, proposals, correspondence,
memoranda, working papers, or any other media which has any bearing on, or disclose any
aspect of, any respondent or potential respondent to the RFP/RFQ above. I will not discuss the
evaluation process with anyone not involved in the evaluation process until its completion.
V I fully understand that it is unlawful for a person to utilize any organization name or auxiliary
organization information, which is not a matter of public record, for personal gain.
VI fully understand that any violation of the above is a basis for disciplinary action, up to and
including termination or referral to the appropriate authorities for further investigation.
CYI am aware that the following firms and subconsultants/subcontractors have submitted
proposals in response to the above referenced solicitation:
List firms including subconsultants/subcontractors:
1.
Dudek
2.
GC Construction Inspection Management
3.
HR Green Pacific
4.
NV5
5.
Proiect Dimensions
6.
Z&K Consultants
LPP 18-01 Page 2 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
� f
Date: I/% % I a Signed: /�- �--- � —7
Name:
Title: ray r a�c�+c•r+ sr ca,� �, r
Dept./Local Agency: F
Employer: c t,r%t . F v^ a y ,..,r t.
CONTRACT ADMINISTRATOR'S REVIEW
I have reviewed the foregoing "Conflict of Interest and Confidentiality Statement" and have
determined, according to the information provided, that this individual:
Date:
❑ does not have a conflict of interest and can participate in the "Selection
Panel'
Qdoes have a conflict of interest and cannot participate in the "Selection Panel"
Signed:
Name:
Title:
Dept./Local Agency:
Employer:
Distribution: Original — Local Agency Consultant File
LPP 18-01 Page 3 of 3
January 2019
i
:i:
�� ��
� _
_ r
..
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
EXHIBIT 10-T CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT
RFP/RFQ PROCUREMENT NUMBERS: CLQ082219
PROJECT NAME:
SilverRock Park Venue Construction Management Services, 2016-08
APPLICABILITY: Applicable to local agency consultant procurements which will contain Federal
or State funds in the consultant contract.
❑ I am an employee of the local agency that is involved in this procurement.
I am an employee of a consultant under contract to the local agency that is responsible for this
procurement but I am not in a management position with the local agency.
❑ I have a personal, financial, or business interest in past employment activity or a personal
relationship regarding the firms (including subconsultants) that are the subject of this
evaluation. A brief description is provided on the back of this form.
9I certify that I have no current contractual relationship with any of the firms (including
subconsultants) that are the subject of this evaluation.
certify that I have no personal or financial interest and no present or past employment activity
r or personal relationship or prior contractual relationship which would be incompatible with my
participation in this solicitation process and I am fully able to give full, fair and impartial
consideration to all proposals/bids as an appointee to the related evaluation.
YI certify that I have read 23 CFR 172.7(b)(4) below and I agree not to participate in selection,
or in the award or administration of a contract supported by Federal funds if a conflict of
interest, real or apparent, would be involved.
23 CFR 172.7(b)(4)
(4) Conflicts of interest. (i) A contracting agency shall maintain a written code of standards of conduct governing the
performance of their employees engaged in the award and administration of engineering and design related services contracts
under this part and governing the conduct and roles of consultants in the performance of services under such contracts to prevent,
identify, and mitigate conflicts of interest in accordance with 2 CFR 200.112, 23 CFR 1.33 and the provisions of this paragraph
(b)(4).
(ii) No employee, officer, or agent of the contracting agency shall participate in selection, or in the award or
administration of a contract supported by Federal -aid funds if a conflict of interest, real or apparent, would be involved:
Such a conflict arises when there is a financial or other interest in the consultant selected for award by:
(A) The employee, officer, or agent;
(B) Any member of his or her immediate family;
(C) His or her partner; or
(D) An organization that employs or is about to employ any of the above.
LPP 18-01 Page 1 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
(iii) The contracting agency's officers, employees, or agents shall neither solicit nor accept gratuities, favors, or
anything of monetary value from consultants, potential consultants, or parties to subagreements. A contracting agency
may establish dollar thresholds where the financial interest is not substantial or the gift is an unsolicited item of
nominal value.
(iv) A contracting agency may provide additional prohibitions relative to real, apparent, or potential conflicts of
interest.
(v) To the extent permitted by State or local law or regulations, the standards of conduct required by this paragraph
shall provide for penalties, sanctions, or other disciplinary actions for violations of such standards by the contracting
agency's officers, employees, or agents, or by consultants or their agents.
(vi) A contracting agency shall promptly disclose in writing any potential conflict of interest to FHWA.
I fully understand and agree to immediately disqualify myself as soon as I am aware of a
conflict of interest that may compromise my fair and impartial consideration of the
proposals/bids.
I certify that I will hold in the strictest confidence all bids, proposals, correspondence,
memoranda, working papers, or any other media which has any bearing on, or disclose any
aspect of, any respondent or potential respondent to the RFP/RFQ above. I will not discuss the
evaluation process with anyone not involved in the evaluation process until its completion.
NPI fully understand that it is unlawful for a person to utilize any organization name or auxiliary
organization information, which is not a matter of public record, for personal gain.
I fully understand that any violation of the above is a basis for disciplinary action, up to and
including termination or referral to the appropriate authorities for further investigation.
I am aware that the following firms and subconsultants/subcontractors have submitted
proposals in response to the above referenced solicitation:
List firms including subconsultants/subcontractors:
1.
Dudek
2.
GC Construction Inspection Management
3.
FIR Green Pacific
4.
NV5
5.
Proiect Dimensions
6.
Z&K Consultants
LPP 18-01 Page 2 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
Date:
Signed: &��
Name: Lo"ss2� Cim
Title: �Vuy k� 24 pr
Dept./Local Agency:
Employer: WE Gy-v `k-S rtia
CONTRACT ADMINISTRATOR'S REVIEW
I have reviewed the foregoing "Conflict of Interest and Confidentiality Statement" and have
determined, according to the information provided, that this individual:
Date:
❑ does not have a conflict of interest and can participate in the "Selection
Panel"
Qdoes have a conflict of interest and cannot participate in the "Selection Panel"
Signed:
Name:
Title:
Dept./Local Agency:
Employer:
Distribution: Original — Local Agency Consultant File
LPP 18-01 Page 3 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
EXHIBIT 10-T CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT
RFP/RFQ PROCUREMENT NUMBERS: CLQ082219
PROJECT NAME:
SilverRock Park Venue Construction Management Services, 2016-08
APPLICABILITY: Applicable to local agency consultant procurements which will contain Federal
or State funds in the consultant contract.
K_I am an employee of the local agency that is involved in this procurement.
❑ I am an employee of a consultant under contract to the local agency that is responsible for this
procurement but I am not in a management position with the local agency.
❑ I have a personal, financial, or business interest in past employment activity or a personal
relationship regarding the firms (including subconsultants) that are the subject of this
evaluation. A brief description is provided on the back of this form.
WI certify that I have no current contractual relationship with any of the firms (including
subconsultants) that are the subject of this evaluation.
�4 I certify that I have no personal or financial interest and no present or past employment activity
or personal relationship or prior contractual relationship which would be incompatible with my
participation in this solicitation process and I am fully able to give full, fair and impartial
consideration to all proposals/bids as an appointee to the related evaluation.
certify that I have read 23 CFR 172.7(b)(4) below and I agree not to participate in selection,
or in the award or administration of a contract supported by Federal funds if a conflict of
interest, real or apparent, would be involved.
23 CFR 172.7(b)(4)
(4) Conflicts of interest. (i) A contracting agency shall maintain a written code of standards of conduct governing the
performance of their employees engaged in the award and administration of engineering and design related services contracts
under this part and governing the conduct and roles of consultants in the performance of services under such contracts to prevent,
identify, and mitigate conflicts of interest in accordance with 2 CFR 200.112, 23 CFR 1.33 and the provisions of this paragraph
(b)(4).
(ii) No employee, officer, or agent of the contracting agency shall participate in selection, or in the award or
administration of a contract supported by Federal -aid funds if a conflict of interest, real or apparent, would be involved.
Such a conflict arises when there is a financial or other interest in the consultant selected for award by:
(A) The employee, officer, or agent;
(B) Any member of his or her immediate family;
(C) His or her partner; or
(D) An organization that employs or is about to employ any of the above.
LPP 18-01 Page 1 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
(iii) The contracting agency's officers, employees, or agents shall neither solicit nor accept gratuities, favors, or
anything of monetary value from consultants, potential consultants, or parties to subagreements. A contracting agency
may establish dollar thresholds where the financial interest is not substantial or the gift is an unsolicited item of
nominal value.
(iv) A contracting agency may provide additional prohibitions relative to real, apparent, or potential conflicts of
interest.
(v) To the extent permitted by State or local law or regulations, the standards of conduct required by this paragraph
shall provide for penalties, sanctions, or other disciplinary actions for violations of such standards by the contracting
agency's officers, employees, or agents, or by consultants or their agents.
(vi) A contracting agency shall promptly disclose in writing any potential conflict of interest to FHWA.
I fully understand and agree to immediately disqualify myself as soon as I am aware of a
conflict of interest that may compromise my fair and impartial consideration of the
proposals/bids.
I certify that I will hold in the strictest confidence all bids, proposals, correspondence,
memoranda, working papers, or any other media which has any bearing on, or disclose any
aspect of, any respondent or potential respondent to the RFP/RFQ above. I will not discuss the
evaluation process with anyone not involved in the evaluation process until its completion.
I fully understand that it is unlawful for a person to utilize any organization name or auxiliary
organization information, which is not a matter of public record, for personal gain.
I fully understand that any violation of the above is a basis for disciplinary action, up to and
including termination or referral to the appropriate authorities for further investigation.
El I am aware that the following firms and subconsultants/subcontractors have submitted
proposals in response to the above referenced solicitation:
List firms including subconsultants/subcontractors:
1.
Dudek
2.
GC Construction Inspection Management
3.
HR Green Pacific
4.
NV5
5.
Proiect Dimensions
6.
Z&K Consultants
LPP 18-01 Page 2 of 3
January 2019
Local Assistance Procedures Manual EXHIBIT 10-T
Conflict of Interest & Confidentiality Statement
Date: 7`1 l q
Signed:
Name:�t�l
Title: C r j IJ�Er
Dept./Local Agency: �-'A-ijnlzyNr/t. /
Employer: 1,� i�%
CONTRACT ADMINISTRATOR'S REVIEW
I have reviewed the foregoing "Conflict of Interest and Confidentiality Statement" and have
determined, according to the information provided, that this individual:
Date:
does not have a conflict of interest and can participate in the "Selection
Panel"
0 does have a conflict of interest and cannot participate in the "Selection Panel"
Signed:
Name:
Title:
Dept./Local Agency:
Employer:
Distribution: Original — Local Agency Consultant File
LPP 18-01 Page 3 of 3
January 2019