Policy Technical Assistance Consultant Request for Qualifications (RFQ)

Organizational Conflict of Interest
Prohibited Conflicts of Interest
First 5 LA shall not contract with, and shall reject any responses submitted by, the persons or entities specified
below unless First 5 LA finds that special circumstances exist which would allow for the award of such contract:
1. First 5 LA employees;
2. Profit-making firms or businesses in which First 5 LA employees serve as officers, principals, partners, or major
shareholders;
3. Persons who, within the immediately preceding 12 months, came within the provisions of number 1, and who:
a. Were employed in positions of substantial responsibility in the area of service to be performed by the
contract; or
b. Participated in any way in developing the solicitation or contract or its service specifications/scope of work;
and
4. Profit-making firms or businesses in which the former employees, described in number 3, serve as officers,
principals, partners, or major shareholders.
By checking this box, you, the proposer, _________________________, hereby represent that you ARE

NOT any of the persons or entities specified above.
Name: Date:
Title:
Organizational Conflict of Interest Disclosure Statement or Representation
It is First 5 LA's policy to avoid situations that place a proposer (or any of its affiliates or proposed consultants or
subcontractors of any tier) in a position where its judgment may be biased because of any past, present, or currently
planned interest (financial, contractual, or otherwise), the proposer may have that relates to the work to be performed
or services to be provided pursuant to this RFP, or where the proposer's performance of such work or services may
provide it with an unfair competitive advantage (collectively, "actual or potential organizational conflicts of interest").
Any proposer with an actual or potential organizational conflict of interest shall review the instructions below and
attach a statement disclosing such actual or potential organizational conflicts of interest. If a proposer has determined
that it has no actual or potential organizational conflict of interest to report, please complete and sign the
representation below.
The refusal to provide the disclosure statement or representation shall result in the proposer's disqualification for
award. The nondisclosure or misrepresentation of any relevant interest may also result in the proposer's
disqualification for award, or if such nondisclosure or misrepresentation is discovered after award, First 5 LA may
terminate the contract for default, and the proposer may be disqualified by First 5 LA from subsequent contracts.
First 5 LA will not make an award until First 5 LA has evaluated the proposer's disclosure statement or representation.
Failure to provide a disclosure statement or representation will be deemed to be a minor informality and the proposer
or contractor shall be required to promptly correct the omission.
Disclosure Statement
The proposer shall attach a signed and dated statement that describes in a concise manner all relevant facts
concerning any actual or potential organizational conflicts of interest that may prevent the proposer from being able
to render impartial, technically sound, and other objective assistance or advise, or that has given the proposer an
unfair competitive advantage.
ORGANIZATIONAL CONFLICT OF INTEREST FORM V4 MODIFIED 2.5.26

The proposal shall provide enough information to allow First 5 LA's meaningful evaluation of the potential effect of the
actual or potential conflict of interest in the performance of the work or services.
The proposer may also provide relevant facts that show how the proposer intends to avoid or mitigate an actual or
potential organizational conflict of interest.
First 5 LA will review each proposer's submitted disclosure statement and may require additional relevant information
from the proposer. All such information, and any other relevant information will be used by First 5 LA to determine
whether an award to the proposer may create an actual or potential organizational conflict of interest. If found to exist,
First 5 LA may (1) impose appropriate conditions that avoid such conflict(s), or (2) disqualify the proposer if no
conditions can be imposed to avoid such conflict(s).
Depending on the nature of the contract activities, the proposer may, because of actual or potential organizational
conflicts of interest, propose to exclude specific kinds of work or services from the proposal, unless the RFP
specifically prohibits such exclusion. Any such proposed exclusion by a proposer shall be considered by First 5 LA
in the evaluation of proposals, and if First 5 LA considers the proposed excluded work to be an essential or integral
part of the required work or services, First 5 LA may reject the proposal as nonresponsive even if the RFP did not
specifically prohibit such exclusion.
Representation (Sign one of the following options):
In the absence of any relevant interest referred to above, the proposer shall certify below that to its best knowledge
and belief no such facts exist relevant to possible organizational conflicts of interest.
By checking this box, you, the proposer, _________________________, hereby represent that you ARE

NOT aware of any actual or potential organizational conflicts of interest relating to the work or services to
be performed under the contract resulting from the RFP/Q titled __________________________ that will
prevent your ability to render impartial, technically sound, and objective assistance or advice or that will
result in you being given an unfair advantage. This representation applies to all your affiliates and your
proposed consultants and subcontractors of any tier.
Name: Date:
Title:
If you are aware of any conflicts of interest or are unsure:
By checking this box, you, the proposer, _________________________, hereby represent that you ARE

aware of actual or potential organizational conflicts of interest relating to the work or services to be performed
under the contract resulting from the RFP/Q titled __________________________ and have attached an
Organizational Conflict of Interest Disclosure Statement to your proposal.
Name: Date:
Title:
ORGANIZATIONAL CONFLICT OF INTEREST FORM V4 MODIFIED 2.5.26