Appendix C_OPM-Form1.pdf
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- Solicitation number
- WCSU-2026-RFP-001
- Issued by
- Fairfield County, Connecticut
About this file
This is the Connecticut Campaign Contribution Certification Form (OPM Form 1), effective July 23, 2021, required by the State of Connecticut for bidders and contractors on state contracts valued at $50,000 or more. The form applies to the Western Connecticut State University (WCSU) Campus Dining Services contract opportunity. Bidders must certify under oath that neither they nor their principals have made campaign contributions to state or General Assembly candidates, party committees, or political committees within the four years preceding the bid submission that were determined by the State Elections Enforcement Commission to violate Connecticut General Statutes Section 9-612 without mitigating circumstances. The certification must be submitted at the time of bid or proposal submission, signed and notarized before a Commissioner of the Superior Court or Notary Public, and must be updated within 30 days if any information changes or upon submission of any new bid for a state contract.
The form requires disclosure of all campaign contributions made on behalf of party committees, exploratory committees, candidates for statewide office, candidates for the General Assembly, or authorized political committees during the four-year period prior to contract signing or bid response, whichever is longer. Bidders must indicate whether the submission is an initial certification or an updated certification due to changed information, and must provide detailed contribution records including contribution dates, contributor names, recipients, contribution values, and descriptions. Failure to complete this form accurately or submission of false information constitutes a false statement subject to penalties under Connecticut law.
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Text version
OPM Form 1
Effective July 23, 2021
STATE OF CONNECTICUT
CAMPAIGN CONTRIBUTION CERTIFICATION
Written or electronic certification to accompany a bid or proposal or a non-competitive contract with a value of $50,000 or more, pursuant to C.G.S. § 9-612.
INSTRUCTIONS:
Complete all sections of the form. Attach additional pages, if necessary, to provide full disclosure about any campaign contributions made to campaigns of candidates for statewide public office or the General Assembly, as described herein. Sign and date the form, under oath, in the presence of a Commissioner of the Superior Court or Notary Public. Submit the completed form to the awarding State agency at the time of submission of your bid or proposal (if no bid or proposal– submit this completed form with the earliest submittal of any document to the state or quasi-public agency prior to the execution of the contract), and if there is a change in the information contained in the most recently filed certification, such person shall submit an updated certification either (i) not later than thirty (30) days after the effective date of such change or (ii) upon the submittal of any new bid or proposal for a contract, whichever is earlier.
Check One:
□ Initial Certification
□ Updated Certification because of change of information contained in the most recently filed certification
CAMPAIGN CONTRIBUTION CERTIFICATION:
I certify that neither the contractor or prospective state contractor, nor any of its principals, have made any contributions to, or solicited any contributions on behalf of, any party committee, exploratory committee, candidate for state-wide office or for the General Assembly, or political committee authorized to make contributions to or expenditures to or for, the benefit of such candidates, in the previous four years, that were determined by the State Elections Enforcement Commission to be in violation of subparagraph (A) or (B) of subdivision
(2) of subsection (f) of Section 9-612 of the General Statutes, without mitigating circumstances having been found to exist concerning such violation. Each such certification shall be sworn as true to the best knowledge and belief of the person signing the certification, subject to the penalties of false statement. If there is any change in the information contained in the most recently filed certification, such person shall submit an updated certification not later than thirty days after the effective date of any such change or upon the submittal of any new bid or proposal for a state contract, whichever is earlier.
All Campaign Contributions on behalf of any party committee, exploratory committee, candidate for state-wide office or for the General Assembly, or political committee authorized to make contributions to or expenditures to or for, the benefit of such candidate, for a period of four years prior to signing the contract or date of the response to the bid, whichever is longer, include:
Contribution Date Name of Contributor Recipient Value Description
OPM Form 1
Effective July 23, 2021
Sworn as true to the best of my knowledge and belief, subject to the penalties of false statement.
Printed Contractor Name Printed Name of Authorized Official
Signature of Authorized Official
Subscribed and acknowledged before me this day of , 20 .
Commissioner of the Superior Court (or Notary Public)
_ My Commission Expires
| INSTRUCTIONS: |
| Check One: |
| CAMPAIGN CONTRIBUTION CERTIFICATION: |
| I certify that neither the contractor or prospective state contractor, nor any of its principals, have made any contributions to, or solicited any contributions on behalf of, any party committee, exploratory committee, candidate for state-wide office ... |
| All Campaign Contributions on behalf of any party committee, exploratory committee, candidate for state-wide office or for the General Assembly, or political committee authorized to make contributions to or expenditures to or for, the benefit of such ... |
| Signature of Authorized Official |
| Initial Certification: Off |
| Updated Certification because of change of information contained in the most recently: Off |
| Contribution Date 1: |
| Contribution Date 2: |
| Contribution Date 3: |
| Contribution Date 4: |
| Contribution Date 5: |
| Contribution Date 6: |
| Contribution Date 7: |
| Printed Contractor Name: |
| Printed Name of Authorized Official: |
| Subscribed and acknowledged before me this: |
| day of: |
| 20: |
| Commissioner of the Superior Court or Notary Public: |
| My Commission Expires: |
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