4-7.Exhibit-D.pdf

EXHIBIT D

STATE FINANCE LAW §§ 139-J AND 139-K

DISCLOSURE, AFFIRMATION AND CERTIFICATION

I. Contractor Disclosure of Findings of Non-Responsibility and Prior Contract Terminations or Withholdings under State Finance Law §139-j:

Name of Individual or Entity Seeking to Enter into the Procurement Contract:

Address: _______________________________________________________________

Name and Title of Person Submitting this Form: ________________________________

Contract Procurement Number: _____________________________________________

Date:________________________

1. Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years? (Please circle):

No Yes

If yes, please answer the next questions:

2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law §139-j?

(Please circle):

No Yes

3. Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Governmental Entity? (Please circle):

No Yes

4. If you answered yes to any of the above questions, please provide details regarding the finding of non-responsibility below.

Governmental Entity: ___________________________________________________________

Date of Finding of Non-responsibility: ______________________________________________

Basis of Finding of Non-Responsibility: _____________________________________________

(Add additional pages as necessary)

5. Has any Governmental Entity or other governmental agency terminated or withheld a Procurement Contract with the above-named individual or entity due to the intentional provision of false or incomplete information? (Please circle):

No Yes

6. If yes, please provide details below.

Governmental Entity: ______________________________________________

Date of Termination or Withholding of Contract: _______________________________________

Basis of Termination or Withholding: ____________________________________________

(Add additional pages as necessary)

Contractor certifies that all information provided to the Governmental Entity with respect to State Finance Law §139-k is complete, true and accurate.

By: Date:

Signature

Name:

Title:

II. Contractor Affirmation Relating to Procedures Governing Permissible Contacts:

Contractor affirms that it understands and agrees to comply with the procedures of Erie County Medical Center Corporation relative to permissible contacts as required by State Finance Law §139-j(3) and §139-j(6)(b).

Date:______________ By: _______________________________________

Name: ________________________________

Title: _________________________________

Contractor Name: _______________________________________________________

Contractor Address: _____________________________________________________