Attachment 1: OCI Disclosure Form

OCI Disclosure Form
Offeror (Prime Contractor or Proposed Subcontractor)
Name of Company
Address
Point of Contact (POC)
POC Telephone
POC E-Mail
For the current
solicitation, are you
planning on bidding as a

Prime

Subcontractor

Affiliate

List Affiliates
(See definition at FAR
9.403.)

SUBMIT ONE COMPLETED ATTACHMENT TO THIS OCI DISCLOSURE FORM PER CONTRACT

This form and its attachments are complete and accurate to the best of my knowledge. I understand that any written guidance I receive from Missile Defense Agency (MDA) concerning Organizational Conflicts of Interest and its attachments, and therefore may change if the Government receives further or different information.

Name and Title of Company Official

Signature and Date

DA-78-F2

INSTRUCTIONS FOR COMPLETING

NOTE: One Attachment to the OCI Disclosure Form shall be submitted for each MDA, Ballistic Missile Defense

System (BMDS) related, or MDA funded contract that has already been awarded and is either currently being performed or was previously performed. Fill in the number and the short official title by which the contract or subcontract requiring analysis and determination is formally known. Place an "X" inside the appropriate box to indicate your responses.

1. Identify below the contract or subcontract held by your firm or affiliate related to MDA BMD work in any way.

Contract or Program Title
Your Company is the

Prime

Subcontractor

Affiliate

Contracting Agency or Customer
Government Contracting Officer
POC (Name, Phone, E-Mail)
Government Technical POC
(Name, Phone, E-Mail)
Contract Number
Task Order Number (if applicable)
Subcontract Number (if applicable)
BAA Number (if applicable)
SBIR/STTR Number (if applicable)

Period of Performance

2. What is the magnitude of this work compared to your company’s overall business base? Percentage (%)
Dollar Value ($)
Number of FTEs

DA-78-F2

3. If you are the subcontractor for the effort identified above, what is your magnitude of work compared to overall contract value (if known)?
Percentage (%)
Dollar Value ($)
Number of FTEs

4. If you performed as a Subcontractor, provide Prime Contractor’s Information. Contractor Name
Address
Telephone

5. Check the boxes below that would apply to the scope of the contract or subcontract as it relates to. Providing Systems Engineering and Technical Direction (FAR 9.505-1) Preparing Specifications or Work Statements (FAR 9.505-2) Providing Technical Evaluation of Offers for Products or Services (FAR 9.505-3)