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ATTACHMENT E <br /> Certification and Disclosure Regarding Potential Conflicts of Interest Certification Form <br /> A sponsor must disclose in writing any potential conflict of interest to the Texas Department of Transportation. No <br /> employee,officer or agent of the sponsor shall participate in selection,or in the award or administration of a contract <br /> supported by federal funds if a conflict of interest,real or apparent,would be involved. Such a conflict would arise <br /> when: <br /> 1. The employee,officer,or agent, <br /> 2. Any member of his immediate family, <br /> 3. His or her partner,or <br /> 4. An organization which employs,or is about to employ, any of the above,has a financial or other interest in the <br /> firm selected for award. The sponsor's officers,employees or agents will neither solicit nor accept gratuities, <br /> favors or anything of monetary value from contractors,potential contractors,or parties to subagreements. <br /> Sponsor may set minimum rules where the financial interest is not substantial or the gift is an unsolicited item <br /> of nominal intrinsic value.To the extent permitted by state or local law or regulations,such standards or <br /> conduct will provide for penalties, sanctions,or other disciplinary actions for violations of such standards by <br /> the grantee's and subgrant recipient's officers,employees,or agents, or by contractors or their agents. <br /> The sponsor must maintain a written code of standards of conduct governing the performance of their employees <br /> engaged in the award and administration of contracts. <br /> I. By checking"Yes,"the sponsor certifies that it does not have any potential conflict of interest or Significant <br /> Financial Interests.By checking"No,"the sponsor discloses that it does have a potential conflict of interest, <br /> which is further explained below. <br /> ❑Yes ❑No <br /> 2. The sponsor maintains a written code of standards of conduct governing the performance of their employees <br /> engaged in the award and achninistration of contracts. By checking"No",the sponsor discloses that it does not <br /> have a written policy,which is further explained below. <br /> ❑Yes ❑No <br /> 3. Explanation of items marked"no": <br /> Sponsor's Certification <br /> I certify,for the project identified herein,responses to the forgoing items are accurate as marked and have the <br /> explanation for any item marked"no"is correct and complete. <br /> I declare under penalty of perjury that the foregoing is true and correct.I understand that lcrrowingly and willfully <br /> providing false information to the federal government is a violation of 18 USC § 1001 (False Statements)and could <br /> subject me to fines,imprisonment,or both. <br /> Signature of Sponsor's Designated Official Representative: <br /> Date: <br /> Page 22 of 44 <br />