Form Cpo160705 "Cpo Idot Construction Conflict of Interest Review and Determination" - Illinois

Form CPO160705 or the "Cpo Idot Construction Conflict Of Interest Review And Determination" is a form issued by the Illinois Department of Transportation.

The form was last revised in July 2, 2018 and is available for digital filing. Download an up-to-date Form CPO160705 in PDF-format down below or look it up on the Illinois Department of Transportation Forms website.

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CPO IDOT Construction
Conflict of Interest
Review and Determination
If a vendor or subcontractor discloses any of the relationships identified in Section 50-35(b) of the Procurement Code, the
Agency must complete this form and submit it to the assigned SPO for further action, which may include forwarding the form
to the CPO or the PPB.
Sections I-V must be completed by the Agency and must not have any blank responses; if a question is not applicable,
complete by stating “N/A”.
SECTION I - AGENCY REQUESTING THE REVIEW
Using Agency
Contact Person
Title
Phone
E-mail
SECTION II - VENDOR/SUBCONTRACTOR INFORMATION NEEDING REVIEW
Name of Vendor/Subcontractor
Contact Person
Title
Phone
E-mail
SECTION III - PROPOSED CONTRACT INFORMATION
Describe the proposed contract
Procurement Bulletin Reference Number
Date Award Posted to Bulletin
Initial Contract
Renewal
This is the:
Contract Number
Contract/Renewal Estimated Start Date
Contract/Renewal Estimated End Date
Describe Future Renewal Options (i.e.1 two-year option)
Total Contract/Renewal Amount
Actual
Estimated
Value is:
The entity with the potential conflict of interest is the:
Prime or Awarded Vendor
Subcontractor
Subcontractor of:
Parent
Parent of:
If this is a conflict of interest review for a subcontractor, what is the estimated value of the subcontract?
What was the original method of procurement used to select this vendor (RFP, IFB, Small Purchase, Sole Source, Emergency, etc.)?
Printed 10/24/19
Page 1 of 3
CPO 160705 (Rev. 07/02/18)
CPO IDOT Construction
Conflict of Interest
Review and Determination
If a vendor or subcontractor discloses any of the relationships identified in Section 50-35(b) of the Procurement Code, the
Agency must complete this form and submit it to the assigned SPO for further action, which may include forwarding the form
to the CPO or the PPB.
Sections I-V must be completed by the Agency and must not have any blank responses; if a question is not applicable,
complete by stating “N/A”.
SECTION I - AGENCY REQUESTING THE REVIEW
Using Agency
Contact Person
Title
Phone
E-mail
SECTION II - VENDOR/SUBCONTRACTOR INFORMATION NEEDING REVIEW
Name of Vendor/Subcontractor
Contact Person
Title
Phone
E-mail
SECTION III - PROPOSED CONTRACT INFORMATION
Describe the proposed contract
Procurement Bulletin Reference Number
Date Award Posted to Bulletin
Initial Contract
Renewal
This is the:
Contract Number
Contract/Renewal Estimated Start Date
Contract/Renewal Estimated End Date
Describe Future Renewal Options (i.e.1 two-year option)
Total Contract/Renewal Amount
Actual
Estimated
Value is:
The entity with the potential conflict of interest is the:
Prime or Awarded Vendor
Subcontractor
Subcontractor of:
Parent
Parent of:
If this is a conflict of interest review for a subcontractor, what is the estimated value of the subcontract?
What was the original method of procurement used to select this vendor (RFP, IFB, Small Purchase, Sole Source, Emergency, etc.)?
Printed 10/24/19
Page 1 of 3
CPO 160705 (Rev. 07/02/18)
SECTION IV - EXPLANATION OF POTENTIAL CONFLICTS OF INTEREST
1. Provide the following information for EACH individual identified as having any of the relationships identified in Section 50-35 (b) of the
Procurement Code
Name of Individual
Describe the Relationship(s) identified in Form A Step 2
Yes
No
Does the relationship disclosed involve an Agency/University employee?
If Yes, complete the following:
Individual's Annual Salary*
Was this individual in a position to influence the State's award
*Applicable only if salary is in
of this contract?
Yes
No
excess of 60% of Governor's salary
Job title and responsibilities
2. Explain the potential or actual conflict of interest
3. Why is it in the best interest of the agency to contract with this vendor despite the potential or actual conflict of interest?
4. Has the PPB previously reviewed the potential conflict of interest in the current fiscal year and recommended no further action?
Yes
No
Date of PPB Review
If yes, describe any change in circumstance and how that might result in a different ruling
5. What is the funding source for this contract? (check all that apply)
Federal Funds
State Appropriated Funds
Other (Explain):
SECTION V - AGENCY REPRESENTATIVE CHECKLIST AND SIGNATURE
The following documents are included with this request to the SPO:
Copy of Agency Internal Approval or waiver of the conflict
Completed and Signed Conflict of Interest Review and Determination Form
Copy of Proposed Contract (may be the proposed contract sent in with an RFP response, a copy of the solicitation response, etc.)
Copy of the Disclosure/Certification Documents Submitted by the Vendor
Prior Procurement Policy Board Conflict of Interest Review Letter for this Vendor
Additional Information
As authorized representative of the Agency, I do not view the relationship disclosed above as creating a potential for a conflict of
interest based on the circumstance and accordingly request authorization to proceed with the contract.
As authorized representative of the Agency, I am submitting this information for review in order to determine whether there is a
potential for a conflict based on the described circumstance, and request authorization to proceed with the contract for the reasons
stated above.
Agency Representative Signature
Agency Representative Printed Name
Date
Agency Representative Title
E-mail Address
Telephone
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CPO 160705 (Rev. 07/02/18)
SECTION VI - STATE PURCHASING OFFICER REVIEW AND SIGNATURE
I do not view the relationship disclosed above as creating a potential for a conflict of interest. The disclosed relationship does not
preclude the Agency from entering into the proposed contract for the supplies or services outlined in this form.
[SPO to send signed form to the Agency --no referral to CPO or PPB necessary]
I find the request and justification is not sufficiently clear and needs CPO review and determination whether the disclosed information
presents a potential for a conflict of interest. [SPO to forward material to CPO]
I find a potential for a conflict of interest and refer this request to the PPB for review and recommendation. All relationships disclosed
under 50-35(b)(1) or (b)(2) are considered as presenting a potential for a conflict. [SPO to scan and email signed copies (keep
originals) to:
matthew.vonbehren@illinois.gov
with cc: to
deanna.rossetto@illinois.gov
and tonya.wallace@illinois.gov.]
Additional Comments
SPO Signature
SPO Printed Name
Date
E-mail Address
Telephone
SECTION VII - CHIEF PROCUREMENT OFFICER REVIEW AND SIGNATURE
(required if SPO refers to CPO for further review)
After considering the material provided, I do not view the relationship disclosed above as creating a potential for a conflict of interest.
The disclosed relationship does not preclude the Agency from entering into the proposed contract.
[CPO to send signed form to SPO for distribution to the Agency]
After considering the material provided, I find a potential for a conflict of interest and refer this request to the PPB for review and
recommendation. The Agency may not enter into the proposed contract pending recommendation of the PPB and subsequent final
determination by the CPO.
[CPO to scan and email signed copies (not originals) of material provided to the PPB.]
Additional Comments
CPO Signature
CPO Printed Name
Date
E-mail Address
Telephone
SECTION VIII - PROCUREMENT POLICY BOARD REVIEW AND SIGNATURE
(required only if SPO/CPO refers to PPB for further review)
After careful review of the documentation provided, I do not view the relationship disclosed above as creating a conflict of interest
sufficient to preclude the Agency from entering into the proposed contract.
After careful review of the documentation provided, I view the relationship disclosed above as creating a conflict of interest sufficient to
preclude the Agency from entering into the proposed contract. The detailed reasons are shown on the attached Recommendation of
the Procurement Policy Board. This recommendation shall be forwarded to the Executive Ethics Commission in accordance with
Section 50-35(d) of the Procurement Code.
Procurement Policy Board Signature
Procurement Policy Board Printed Name
Date
Telephone
E-mail Address
Printed 10/24/19
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CPO 160705 (Rev. 07/02/18)
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