Contractor's Certifications pursuant to State Finance Law § 139-j and § 139-k
This form shall be completed and submitted with your bid. Failure to complete and submit this form may result in a determination of non-responsiveness and disqualification of the bid.
I. Contractor Affirmation relating to procedures governing permissible
contacts:
(Contractor Must Check Applicable Box)
Contractor: __affirms __does not affirm
that it understands and has to date and agrees hereinafter to comply with
the Dormitory Authority’s procedures relative to permissible contacts
for this procurement as required by State Finance Law § 139-j (3) and
§ 139–j (6) (b).
II. Contractor Disclosure of Findings of Non-Responsibility and Prior Contract
Terminations or Withholdings under the 2005 Procurement Lobbying Law:
1. Has any "governmental entity," as defined in State Finance Law
§ 139-j and § 139-k made a finding in the last four years that the
Contractor was not responsible?
__No __Yes
2. If yes, was the basis for any such finding(s) the intentional provision
of false or incomplete information required by State Finance Law § 139-j
and § 139-k, and/or the failure to comply with the requirements of State
Finance Law § 139-j (3) relating to permissible contacts?
__No __Yes
If yes, please provide details regarding each finding of non-responsibility
below. (Attach additional pages, if necessary.)
Governmental Entity:_______________________________________________________
Date of Finding:___________________________________________________________
Basis of Finding:__________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. Has any "governmental entity" as defined in State Finance Law § 139-j and § 139-k terminated or withheld a procurement contract with the Contractor due to the intentional provision of false or incomplete information required by such Laws and/or the failure to comply with the requirements of State Finance Law § 139-k(3) relating to permissible contacts?
__No __Yes
If yes, please provide details below. (Attach additional pages, if necessary)
Governmental Entity:_______________________________________________________
Date of Termination or Withholding of Contract:_________________________________
Basis of Termination or Withholding of Contract:_________________________________
________________________________________________________________________
The undersigned acknowledges that intentional submission of false or misleading information may constitute a felony under Penal Law Section 210.40 or a misdemeanor under Penal Law Section 210.35 or Section 210.45, and may also be punishable by a fine of up to $10,000 or imprisonment of up to five years under 18 U.S.C. Section 1001; and states that all information provided to the Dormitory Authority with respect to State Finance Law § 139–j and § 139–k is complete, true and accurate.
Signature:____________________________________
Date:________________________________________
Contractor:___________________________________
Address:_____________________________________
____________________________________________
Name:_______________________________________
Title:________________________________________