3-RFP 02 Campaign Contribution Form.pdf

CAMPAIGN CONTRIBUTION FORM

Incorporated County of Los Alamos Procurement Division

101 Camino Entrada, Building 3 Los Alamos, NM 87544

Version: 20250318

Any prospective contractor seeking to enter into a contract with the Incorporated County of Los Alamos must submit this form disclosing whether they, a family member or a representative of the prospective contractor have made a campaign contribution to an applicable public official during the two (2) years prior to the date on which prospective contractor submits a proposal or, in the case of a sole source or small purchase contract, the two (2) years prior to the date prospective contractor signs the contract.

THIS FORM MUST BE SUBMITTED BY ANY PROSPECTIVE CONTRACTOR WHETHER OR NOT

THEY, THEIR FAMILY MEMBER, OR THEIR REPRESENTATIVE HAVE MADE ANY CONTRIBUTIONS

SUBJECT TO DISCLOSURE.

The following definitions apply:

“Applicable public official” means a person elected to an office or a person appointed to complete a term of an elected office, who has the authority to award or influence the award of the contract for which the prospective contractor is submitting a competitive sealed proposal or who has the authority to negotiate a sole source or small purchase contract that may be awarded without submission of a sealed competitive proposal.

“Campaign Contribution” means a gift, subscription, loan, advance or deposit of money or other things of value, including the estimated value of an in-kind contribution, that is made to or received by an applicable public official or any person authorized to raise, collect or expend contributions on that official’s behalf for the purpose of electing the official to either statewide or local office. “Campaign Contribution” includes the payment of a debt incurred in an election campaign, but does not include the value of services provided without compensation or unreimbursed travel or other personal expenses of individuals who volunteer a portion or all of their time on behalf of a candidate or political committee, nor does it include the administrative or solicitation expenses of a political committee that are paid by an organization that sponsors the committee.

“Contract” means any agreement for the procurement of items of tangible personal property, services, professional services, or construction.

“Family member” means a spouse, children, parents, brothers and sisters, parent in-law, grandparent, grandchild, and step-relatives in a like relationship: of:

(a) a prospective contractor, if the prospective contractor is a natural person; or

(b) an owner of a prospective contractor.

“Pendency of the procurement process” means the time period commencing with the public notice of the request for proposals and ending with the award of the contract or the cancellation of the request for proposals.

“Person” means any corporation, partnership, individual, joint venture, association or any other private legal entity.

“Prospective contractor” means a person who is subject to the competitive sealed proposal process set forth in the Procurement Code or is not required to submit a competitive sealed proposal because that person qualifies for a sole source or a small purchase contract.

Version: 20250318

“Representative of a prospective contractor” means an officer or director of a corporation, a member or manager of a limited liability corporation, a partner of a partnership or a trustee of a trust of the prospective contractor.

DISCLOSURE OF CONTRIBUTIONS: (Report any applicable contributions made to the following- COUNTY COUNCILORS: Theresa Cull; Melanee Hand; Susie Havemann; Ryn Hermann; Beverly Neal-Clinton; David Reagor; and Randal Ryti.)

Contribution Made By:

Relation to Prospective Contractor:

Name of Applicable Public Official:

Contribution(s) Date(s)

Contribution Amount(s):

Nature of Contribution(s): Purpose of Contribution(s):

(Attach extra pages if necessary)

Please check the box next to the applicable statement.

CONTRIBUTIONS IN THE AGGREGATE TOTAL OVER TWO HUNDRED FIFTY DOLLARS ($250.00)

WERE MADE to an applicable public official by me, a family member or representative, and I have disclosed those contributions.

NO CONTRIBUTIONS IN THE AGGREGATE TOTAL OVER TWO HUNDRED FIFTY DOLLARS ($250.00)

WERE MADE to an applicable public official by me, a family member or representative.

Signature Date

Title (position)