SAMPLE DOCUMENT. All names and facts are fictional.

CITY OF HARLOW CREEK, GEORGIA
RFP HC-2026-014
FORM B: CONFLICT OF INTEREST DISCLOSURE

Respondent name: ______________________________
Authorized representative: ______________________________

Part 1. Relationships within the last 36 months.
Within the last 36 months, has the respondent, any principal, any key team member or any proposed subcontractor performed work for, received payment from, or held a business relationship with any of the following? Mark Yes or No for each.

(a) Larkin Digital Infrastructure, LLC or any affiliate: Yes / No
(b) Any other data center developer or operator: Yes / No
(c) Any hyperscale technology company: Yes / No
(d) Any electric utility or electric membership corporation: Yes / No
(e) Any water or sewer utility or water authority: Yes / No

Part 2. Details.
For each Yes answer, state the name of the other party, the dates, the nature of the work, the approximate value, and whether any person on the proposed team did the work.

Part 3. Contingent fees.
The respondent certifies that no fee under this engagement depends on whether the Project is approved, denied or built. Yes / No

Part 4. Independence practices.
Describe, in no more than 300 words, the practices the respondent will use to stay independent of the Developer and to handle any conflict that arises during the engagement.

Part 5. Certification.
I certify that the information provided is true and complete to the best of my knowledge.

Signature: ______________________   Title: ______________________   Date: ______________