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28 <br /> EXHIBIT C <br /> CONTRACT CONFLICT OF INTEREST DISCLOSURE FORM <br /> FOR OFFICIALS,EMPLOYEES,AND AGENTS <br /> Orange County("Unit")has adopted a Conflict of Interest Policy("Policy")that governs the Unit's <br /> expenditure of Federal Financial Assistance(as defined in Section II of the Policy). The Policy designates <br /> the Chief Financial Officer as the"COI Point of Contact." <br /> The COI Point of Contact has identified you as an official, employee,or agent of the Unit that may <br /> be involved in the selection, award, or administration of the following contract: <br /> (the"Contract"). To safeguard the Unit's expenditure of Federal <br /> Financial Assistance,the COI Point of Contact has requested that you identify any potential real or apparent <br /> conflicts of interest in the Firm considered for the award of a Contract. Using the Exhibit A to the Policy <br /> as a guide,please answer the following questions: <br /> 1. Do you have a financial or other interest in a firm considered for this Contract? <br /> Yes No Unsure: <br /> If the answer is Yes or Unsure,please explain: <br /> 2. Will you receive any tangible personal benefit from a firm considered for this Contract? <br /> Yes No Unsure: <br /> If the answer is Yes or Unsure,please explain: <br /> 3. For purposes of Question 3(a) and 3(b), your "Immediate Family Members" include: (i) your spouse <br /> and their parents, (ii) your child, (iii)your parent and any spouse of your parent, (iv)your sibling and <br /> any spouse of your sibling, (v) your grandparents or grandchildren, and the spouses of each, (vi) any <br /> domestic partner of any individual in(ii)through(v) of this definition; and(vii)any individual related <br /> by blood or affinity whose close association with you is the equivalent of a family relationship. <br /> a. Do you have an Immediate Family Member with a financial or other interest in a <br /> firm considered for this Contract? <br /> Yes No Unsure: <br /> If the answer is Yes or Unsure,please explain: <br /> C-1 <br />