3-J-3.pdf
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- Solicitation number
- 2014
- Issued by
- Alexandria City, Virginia
About this file
This is a Disclosures Relating to City Officials and Employees form required for the Beauregard Street Shared Use Path project in the City of Alexandria, Virginia. The form serves as a bidder certification document in which the submitting firm must declare whether any member of the City Council, city officials, employees, or members of city-appointed commissions, committees, boards, or corporations have received or been promised any commission, finder's fee, or other thing of value in connection with the contract. Additionally, the form requires bidders to disclose whether any city council members, officials, or employees would or may be financially affected, whether affirmatively or negatively and either personally or through a spouse or family member, should the contract be awarded to the firm.
The form provides two sections with checkbox options for bidders to indicate either that they have no reason to believe such disclosures exist, or alternatively to identify specific individuals by name and title/position if they do have reason to believe such relationships or financial interests exist. The form requires execution by an authorized signatory of the bidding firm and must be dated at the time of submission.
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Text version
J-3
DISCLOSURES RELATING TO CITY OFFICIALS AND EMPLOYEES
A. I hereby state that, as of this date (check one):
( ) Our firm has no reason to believe that any member of the City Council, any official or employee of the City, or any member of any commission, committee, board or corporation controlled or appointed by the City Council has already received, in connection with or related in any way to this Contract, or has been promised, in the event this Contract is awarded to the firm, any commission, finder's fee or other thing of value
( ) Our firm has reason to believe that the following City Council members, City officials and/or employees, and/or members of a Council-appointed or -controlled commission, committee, board or corporation have already received, in connection with or related in any way to this Contract, or have been promised, in the event this Contract is awarded to the firm, any commission, finder's fee or other thing of value:
Name Title/Position
B. I hereby state that, as of this date:
( ) Our firm has no reason to believe that any member of the City Council or any official or employee of the City would or may be financially affected, whether affirmatively or negatively, and whether personally or through a spouse or other family member, if this Contract were awarded to the firm
( ) Our firm has reason to believe that the following members of the City Council and officials and employees of the City would or may be financially affected, whether affirmatively or negatively, and whether personally or through a spouse or other family member, if this Contract were awarded to the firm:
Bidder’s Name
Bidder’s Authorized Signatory Date
Name and Title of Bidder’s Authorized Signatory
File details come from the government source that posted it. Updated .