Conflicts of Interest - Contracts

A state officer, employee, or special state appointee may not knowingly have a financial interest in a contract made by an agency. The term financial interest is defined in IC 4-2-6-1. This prohibition, however, does not apply to an officer, employee, or special state appointee who (1) does not participate in or have contracting responsibility for the contracting agency and (2) meets the criteria in IC 4-2-6-10.5(b)(2) and (c)(1)-(5). One criterion is that the officer, employee, or special state appointee must file a written statement with the Inspector General before the officer, employee, or special state appointee executes the contract with the state agency.

The foregoing consists only of excerpts from IC 4-2-6-10.5. Care should be taken to review IC 4-2-6-10.5 in its entirety to ensure compliance with all criteria set forth in the statute. This disclosure will be posted on the Inspector General’s website.

Check if you are making a correction to a previously filed statement.
 
PART 1 – GENERAL INFORMATION
*Name (Last) *Name (First) Name (Middle)
*Office Address *City *Zip Code
*Title or position within agency: *Name of agency: Office Telephone:
*Email Address:

 

PART 2 – CONTRACT
List the name for each entity (i.e. vendor, contractor, consultant, subcontractor, or subconsultant) in which you have a financial interest that has a contract with a state agency. Also, list the name of the state agency the entity is contracting with (use a different form for each contract)
Entity’s business name: Entity contact person’s name (first name & last name):
This contract was (check one):
made after public notice and, if applicable, through competitive bidding
         or
not subject to notice and bidding requirements
Description(s) of Contract(s): (Describe the type of contract involved and the effective date and term of the contract if reasonably determinable.)
Description of the Financial Interest: (Describe in what manner the state officer, employee, or special state appointee expects to derive a financial interest from or otherwise has a pecuniary interest in, the above contract. State the approximate dollar value of the interest if reasonably determinable. Attach extra pages if additional space is needed.)

 

PART 3 – AGENCY CERTIFICATION

Approval of appointing authority (to be completed in the case of a contract for professional services only.)
Being the

of

I hereby affirm that no other state officer, employee, or special state appointee of

is available to perform those services as part of the regular duties of the state officer, employee, or special state appointee.

 

PART 4 – AFFIRMATION

I submit this statement to the Inspector General pursuant to 42 IAC 1-5-7 (IC 4-2-6-10.5) to disclose my financial interest in a contract with an agency. This contract can be performed without compromising the performance of my official duties and responsibilities as a state officer, employee or special state appointee. I affirm that I do not participate in or have contracting responsibility for the contracting agency. I further affirm that the contract was made after public notice or competitive bidding, if applicable. I also affirm, under penalty of perjury, the truth and completeness of the statements made above and that I am the above named state officer, employee, or special state appointee.

Signed: Date: (month, day, year)