Mississippi Administrative Code
Title 12 - Finance and Administration
Part 9 - Office of Personal Service Contract Review Rules and Regulations
Chapter 6 - REQUESTS FOR PROPOSALS AND REQUESTS FOR QUALIFICATIONS
Exhibit 12-9-6-1 - Sample Conflict of Interest Certification
**This is a sample document. Agencies are not required to use this specific format.**
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[Agency Name] Request for [Proposals, Qualifications]
[Type of Services Solicited] RFx # [1234567890]
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CONFLICT OF INTEREST CERTIFICATION
Name: ___________________________________________
I am a(n) ____ member of the Evaluation Committee.
____ advisor to the Evaluation Committee.
____ Agency official responsible for management of the procurement.
I ____ have reviewed a list of all Offerors who responded to RFx # [1234567890].
____ have not reviewed a list of all Offerors who responded to RFx # [1234567890].
I ____ have reviewed the Mississippi Ethics in Government laws.
____ have not reviewed the Mississippi Ethics in Government laws.
*The Mississippi Ethics in Government laws are codified at Mississippi Code Annotated §§ 25-4-101 through 25-4-121 and are attached hereto.
I hereby certify that I have no personal, financial, or familial interest in any of the contract offerors, or principals thereof. I have reviewed the conflict of interest standards prescribed herein and I do not have a conflict of interest with respect to the evaluation of this proposal or qualification. I further certify that neither I nor any member of my immediate family are engaged in any negotiations or arrangements for prospective employment or association with any of the offerors submitting proposals or qualifications or their parent or subsidiary organization.
Signature: __________________________________________
Date/Time: [Must be prior to Date/Time Evaluation Begins]
Date/Time Evaluation Begins: [Must be after Date/Time Certification Executed]
[Attach a copy of the most current version of the Mississippi Ethics in Government Law, Mississippi Code Annotated §§ 25-4-101 through 25-4-121.]
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