4-Supporting Documents 3 Campaign Contributions Disclosure Form.pdf
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- Solicitation number
- US.261862
- Issued by
- Delaware County, Pennsylvania
About this file
This file is a Campaign Contributions Disclosure Form required by the City of Chester, Pennsylvania for bidders participating in the procurement process for the Lead-Safe and Healthy Homes Program. The form requests detailed information regarding campaign contributions made by the bidding firm, its officers, directors, controlling shareholders, partners, and affiliates to the City of Chester. The disclosure encompasses eleven yes-or-no questions addressing whether the firm or related parties have made contributions, solicited contributions, served as intermediaries for contributions, reimbursed contributions, or controlled political committees that made contributions. The form specifies that legally disclosed campaign contributions do not automatically disqualify a bidder from contract consideration and that disclosure is mandatory as part of the City's procurement procedures.
For any affirmative responses, bidders must provide supplementary details including the contributor's name, relationship to the firm, contribution recipient, date, and amount. The form requires completion with the bidder company name, contact information, title, signature, date, email, and phone number. Additionally, the form requests the City of Chester bid number and project name to correlate the disclosure with the specific solicitation for lead abatement contractors needed to provide lead remediation services for approximately 120 residential properties over a three-year period under the HUD-funded Lead Hazard Reduction Grant administered by the City of Chester's Bureau of Health.
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Text version
Chester City Hall, Municipal Building, 1 East 4th Street, Chester, Pennsylvania, 19013
Campaign Contributions Disclosure Form
Please note that legally disclosed campaign contributions do not automatically disqualify a bidder from participating as a contractor. The City of Chester must obtain this information as part of its procurement process.
1. Has your firm made any contributions to the City of Chester? Yes ___ No ___
2. Has your firm solicited or served as an intermediary for any contributions? Yes ___ No ___
3. Has an officer, director, controlling shareholder, or partner of your firm solicited or served as an intermediary for any contributions?
Yes ___ No ___
4. Has an affiliate of your firm made any contributions? Yes ___ No ___
5. Has an affiliate of your firm solicited or served as an intermediary for any contributions?
Yes ___ No ___
6. Has an officer, director, controlling shareholder, or partner of a for-profit affiliate of your firm made any contributions?
Yes ___ No ___
7.
Has an officer, director, controlling shareholder, or partner of a for-profit affiliate of your firm solicited or served as an intermediary for any contributions?
Yes ___ No ___
8.
Has your firm or an affiliate of your firm business reimbursed another individual or business for a contribution that the individual or business has made?
Yes ___ No ___
9.
Has an officer, director, controlling shareholder, or partner of a for-profit business, or of a for-profit affiliate of your firm, reimbursed another individual or business for a contribution that the individual or business has made?
Yes ___ No ___
10. Has a political committee controlled by your firm or by an affiliate of your firm, made any contributions?
Yes ___ No ___
11.
Has a political committee controlled by an officer, director, controlling shareholder, or partner of the for-profit business, or of a for-profit affiliate of your firm, made any contributions?
Yes ___ No ___
Chester City Hall, Municipal Building, 1 East 4th Street, Chester, Pennsylvania, 19013
Campaign Contributions Disclosure Form
For any “Yes” answers on the previous page, please provide the following details:
Name of Contributor
Relationship to Your firm
Recipient of the Contribution Date Amount ($)
City of Chester Bid Number
City of Chester Project Name
Bidder Company Name
Bidder Company Contact Name
Title
Signature
Today’s Date
Phone
File details come from the government source that posted it. Updated .