2-Attachment C - Contract Affidavit Sample.pdf

Attachment C Contract Affidavit Sample

Procurement Maryland Judiciary – mdcourts.gov/procurement

A. AUTHORITY:

I HEREBY AFFIRM THAT:

I, ______________________________________________ (print name), possess the legal authority to make this Affidavit.

B. CERTIFICATION OF REGISTRATION OR QUALIFICATION WITH THE STATE DEPARTMENT OF

ASSESSMENTS AND TAXATION

I FURTHER AFFIRM THAT: ________________________________________________________________ The business named above is a (check applicable box):

(1) Corporation domestic or foreign;

(2) Limited Liability Company domestic or foreign;

(3) Partnership domestic or foreign;

(4) Statutory Trust domestic or foreign;

(5) Sole Proprietorship and is registered or qualified as required under Maryland Law. I further affirm that the above business is in good standing both in Maryland and (IF APPLICABLE) in the jurisdiction where it is presently organized and has filed all of its annual reports, together with filing fees, with the Maryland State Department of Assessments and Taxation.

The name and address of its resident agent (IF APPLICABLE) filed with the State Department of Assessments and Taxation is: if none, so state:

Name: _____________________________________________________________________________________ Department ID Number: _______________________________________________________________________ Address:____________________________________________________________________________________ and that if it does business under a trade name, it has filed a certificate with the State Department of Assessments and Taxation that correctly identifies that true name and address of the principal or owner as: if none, so state:

Name: _____________________________________________________________________________________ Department ID Number: _______________________________________________________________________ Address:____________________________________________________________________________________

C. POLITICAL CONTRIBUTION DISCLOSURE AFFIRMATION

I FURTHER AFFIRM THAT: I am aware of, and the above business will comply with, Election Law Article, §§14 101 — 14-109, Annotated Code of Maryland, which requires that every person that enters into contracts, leases, or other agreements with the State of Maryland, including its agencies or a political subdivision of the State, during a calendar year in which the person receives in the aggregate $200,000 or more shall file with the State Board of Elections a statement disclosing contributions in excess of $500 made during the reporting period to a candidate for elective office in any primary or general election.

D. CERTAIN AFFIRMATIONS VALID

I FURTHER AFFIRM THAT: To the best of my knowledge, information, and belief, each of the affirmations, certifications, or acknowledgements contained in that certain Bid/Proposal Affidavit dated ________ , 20___ , and

Procurement Maryland Judiciary – mdcourts.gov/procurement executed by me for the purpose of obtaining the contract to which this Exhibit is attached remains true and correct in all respects as if made as of the date of this Contract Affidavit and as if fully set forth herein.

I do solemnly declare and affirm under the penalties of perjury that the contents of this affidavit are true and correct to the best of my knowledge, information, and belief.

SIGNATURE OF AUTHORIZED REPRESENTATIVE & AFFIANT DATE

PRINT NAME OF AUTHORIZED REPRESENTATIVE & AFFIANT

TITLE OF AUTHORIZED REPRESENTATIVE & AFFIANT