Annual Required Affidavit for Bidders Attachment A without table.xml

%USERNAME% Smith, Sarah E (CHFS OATS DPS) 4 14 2019-01-15T20:04:00Z 2019-01-28T13:34:00Z 1 933 5323 Commonwealth of Kentucky 44 12 6244 16 0x010101005BCC69058D4E7643B4ACF42C2563517B A TTACHMENT A ANNUAL AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS Affidavit Effective Date : _________________________ Affidavit Expiration Date: _________________________ Maximum Length One-Year REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS FOR BIDS AND CONTRACTS IN GENERAL: Each bidder or offeror swears and affirms under penalty of perjury, that: In accordance with KRS 45A.110 and KRS 45A.115 , neither the bidder or offeror as defined in KRS 45A.070(6) , nor the entity which he/she represents, has knowingly violated any provisions of the campaign finance laws of the Commonwealth of Kentucky; and the award of a contract to the bidder or offeror or the entity which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and all subcontractors therein, are aware of the requirements and penalties outlined in KRS 45A.485 ; have properly disclosed all information required by this statute; and will continue to comply with such requirements for the duration of any contract awarded. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and its affiliates, are duly registered with the Kentucky Department of Revenue to collect and remit the sales and use tax imposed by KRS Chapter 139 , and will remain registered for the duration of any contract awarded. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding is not delinquent on any state taxes or fees owed to the Commonwealth of Kentucky and will remain in good standing for the duration of any contract awarded. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding, is not currently engaged in, and will not for the duration of the contract engage in, the boycott of a person or an entity based in or doing business with a jurisdiction with which Kentucky can enjoy open trade, as defined in Executive Order No. 2018-905. The bidder or offeror swears and affirms that the entity bidding, and all subcontractors therein, have not violated any of the prohibitions set forth in KRS 11A.236 during the previous ten (10) years, and further pledge to abide by the restrictions set forth in such statute for the duration of the contract awarded. FOR “NON-BID” CONTRACTS (I.E. SOLE-SOURCE; NOT-PRACTICAL OR FEASIBLE TO BID; OR EMERGENCY CONTRACTS, ETC): Each contractor further swears and affirms under penalty of perjury, that: In accordance with KRS 121.056 , and if this is a non-bid contract, neither the contractor, nor any member of his/her immediate family having an interest of 10% or more in any business entity involved in the performance of any contract awarded, have contributed more than the amount specified in KRS 121.150 to the campaign of the gubernatorial slate elected in the election last preceding the date of contract award. In accordance with KRS 121.330(1) and (2) , and if this is a non-bid contract, neither the contractor, nor officers or employees of the contractor or any entity affiliated with the contractor, nor the spouses of officers or employees of the contractor or any entity affiliated with the contractor, have knowingly contributed more than $5,000 in aggregate to the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract award. In accordance with KRS 121.330(3) and (4) , and if this is a non-bid contract, to the best of his/her knowledge, neither the contractor, nor any member of his/her immediate family, his/her employer, or his/her employees, or any entity affiliated with any of these entities or individuals, have directly solicited contributions in excess of $30,000 in the aggregate for the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract. As a duly authorized representative for the bidder, offeror, or contractor, I have fully informed myself regarding the accuracy of all statements made in this affidavit, and acknowledge that the Commonwealth is reasonably relying upon these statements, in making a decision for contract award and any failure to accurately disclose such information may result in contract termination, repayment of funds and other available remedies under law. Signature: _____________ ______________ P rinted Name: _________________ _______________ Title: ________________________________ Date: ____________________ ___________________ Company Name: ______________ _______________________________ ________________________ Address: _____________ _______________________________ _______________________________ _____________ _______________________________ _______________________________ City, State, Zip: ___ _______________________________ ____________________________________ Commonwealth Vendor Code (if known): __________________________________________________ Subscribed and sworn before me by _______________________________ _______________________ (Affiant) (Title) of _____________ _________ _______________________ this __ ___ day of _________ _ _____, 20___. (Company Name) ____________________________________________________________________________________ Notary Public [ seal of notary] My commission expires: ________________ Annual Affidavit for Bidders, Offerors , and Contractors ATTACHMENT A Page 1 of 2