3-J-4 Disclosures Relating to City Officials and Employees.pdf
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- Attached to
- Colonial Avenue Sewer Separation
- Solicitation number
- 2000
- Issued by
- Alexandria City, Virginia
About this file
This is a Disclosures Relating to City Officials and Employees form associated with the Colonial Avenue Sewer Separation project in Virginia. The form requires bidders to disclose any financial relationships, promises of compensation, or potential conflicts of interest involving City Council members, city officials, employees, or members of city-appointed boards and commissions. The Colonial Avenue Sewer Separation project involves installing 192 feet of 12-inch PVC pipe using horizontal boring methods, replacing 351 feet of existing PVC pipe, installing and connecting to manholes, and reconnecting laterals.
The disclosure form contains two primary certification sections. Section A requires bidders to certify whether any city officials or employees have received or been promised commissions, finder's fees, or other things of value in connection with the contract. Section B requires bidders to disclose whether any City Council members or city employees would be financially affected by the contract award, whether positively or negatively, either personally or through family members. Bidders must identify the specific individuals and their titles if such relationships or potential conflicts exist. The form requires signature and certification by an authorized bidder signatory and includes fields for multiple authorized representatives to be listed.
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Text version
J-4, 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
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:
Name Title/Position
Name Title/Position
Bidder’s Name Bidder’s Authorized Signatory Date Name and Title of Bidder’s Authorized Signatory
| Name: |
| TitlePosition: |
| Name_2: |
| TitlePosition_2: |
| Name_3: |
| TitlePosition_3: |
| Name_4: |
| TitlePosition_4: |
| Bidders Name: |
| Date: |
| Signature15_es_:signer:signature: |
| Signature16_es_:signer:signature: |
| Check Box1: Off |
| Check Box2: Off |
| Check Box3: Off |
| Check Box4: Off |
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