Facility Name:__________________________ Fin/Sub No._____________________ Address: ______________________________ City, ST, ZIP:___________________
Effective March 1, 2014 (Revision 2) Appendix A_Conflict of Interest Certification Real Estate Conflict of Interest Certification
To avoid actual or apparent conflicts of interest, the United States Postal Service (“Postal Service”) requires the following certification from you as a potential Tenant/Landlord/Licensor/Supplier/Contractor to the Postal Service. Please check all that a pply in item A below. Further, please understand that the Postal Service will be relying on the accuracy of the statements made by you in this certification in determining whether to proceed with any possible transaction with you.
I, _____________________________________ hereby certify to the Postal Service as follows:
[PRINT: name of potential Tenant/Landlord/ Licensor/Supplier/Contractor]
A. (Check all that apply) I am:
(i) _______A Postal Service employee;
(ii) ______The spouse of a Postal Service employee;
(iii) ______A family member of a Postal Service employee; (Relationship) _________________ (iv) ______An individual residing in the same household as a Postal Service employee ; (v) ______I am one of the individuals listed in (i) through (iv) above AND a controlling shareholder or owner of a business organization leasing or licensing space or intending to lease or license space to/from the Postal Service; OR
(vi) _____ None of the above.
B. (Complete as applicable):
i. I have the following job with the Postal Service(Title) ___________________________ (Location)__________________________________
ii. My Spouse who works for the Postal Service holds the following job:
(Title) ___________________________ (Location)__________________________________ iii. My family member who works for the Postal Service holds the following job:
(Title) ___________________________ (Location)__________________________________ iv. My household member who works for the Postal Service holds the following job:
(Title) ___________________________ (Location)__________________________________
C. If you have checked “none of the above” and during the lease or license term or any renewal term, you do fall into any of the categories listed in A (i) through (v) above, you shall notify the Postal Service Contracting Officer in writing within 30 days of the date you fall into any of the such categories and shall include an explanation of which of the above categories now applies.
D. The person signing this certification has full power of authority to bind the potential Tenant/Landlord/ Supplier/Contractor named above.
Executed this _____ day of ________, 20___ by
BY:___________________________________
[Insert Signature]
BY:___________________________________
[PRINT: name of entity or person]
Title:__________________________________
[Insert title]
Facility Name:__________________________ Fin/Sub No._____________________ Address: ______________________________ City, ST, ZIP:___________________
Effective March 1, 2014 (Revision 2) Appendix A_Conflict of Interest Certification
[INTERNAL USE ONLY: 1) If A(vi) ‘none of the above’ is selected, stop, file form with the lease/license/out- sublease. 2) If other items are selected, submit form to [email protected]. File form and Ethics determination with the lease/license/out-sublease.]