Appendix E Vendor Disclosure Form.docx

STATE OF COLORADO

COLORADO LOTTERY DIVISION

VENDOR DISCLOSURE FORM Comment by Sherri Gibson: Offerors: This form is included for information only. See Appendix A, RFP Administrative Information, 31. Subcontractors and Consultants.

December 2010

GENERAL INSTRUCTIONS

Dated: __________

Type an answer to every question. If a question does not apply, so state with N/A. If space is insufficient, continue on a separate page and precede each answer with the section number and appropriate title. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification.

The applicant (company president, CEO or company representative) must initial each page, including attached pages. The applicant is attesting to the accuracy and completeness of the information contained on that page.

The information you provide in this form will be used to determine whether the Colorado Lottery may enter into a contract with you or your company. Any misrepresentation of information requested in this form, or failure to provide information requested in this form, may be deemed sufficient cause for the Lottery to refuse to enter into a contract or to terminate a contract which is based on the information you provide.

The costs of any investigation into the background of the applicant shall be assessed against the applicant and shall be paid by the applicant at the time of billing by the Colorado State Lottery and no contract may be signed until the investigation is completed.

3. INCORPORATION/ORGANIZATION

If the business is a corporation, complete the following (if a partnership or other form of business organization, furnish similar information as shown below):

e. If known, list each person originally involved in the organization of this company by name and current address.

4. GAMING/GAMBLING LICENSES, GOODS AND SERVICES

a. If “Yes”, list the license or permit type, license number (if applicable), jurisdiction, regulatory agency, agency address, agency contact person, agency telephone, date of licensing or permit, and license status on a separate page.

b. If any gaming license has been revoked or suspended, provide complete details.

c. List all states or places where your company contracts to supply gaming goods or services and to whom those goods or services are provided.

5. STOCKHOLDERS/PARTNERS

This company is a PUBLICLY TRADED CORPORATION:

Yes [ ] No [ ]

If NO: Attach a complete list of all officers, directors, and stockholders/partners, persons owning, directly or indirectly, any equity security, and persons owning any other equity interest showing each person’s full name, address, date of birth, social security number, office or interest, and the number of shares/percentage of interest held of record by each.

If YES: Attach a complete list of all names and addresses of all persons owning five percent (5%) or more of securities and the number of shares owned by each. A completed PERSONAL DISCLOSURE FORM is required for any persons holding five percent (5%) or more interest.

6. CONTROL PERSONS

A complete list of all CONTROL PERSONS (corporate officers, directors, partners, key employees, and management contractors) is attached.

Yes [ ] No [ ]

List full name, title, residence address, date of birth and social security number of each control person on a separate page.

If NO, state reason

7. PERSONAL DISCLOSURE FORMS

A completed PERSONAL DISCLOSURE FORM for each CONTROL PERSON (Section 6) is attached.

Yes [ ] No [ ]

If NO, state reasons

8. HOLDING COMPANIES/OTHER INTEREST HOLDERS

List all holding companies, business organizations, or other entities which hold any financial interest in this company. Include companies which have liens or other financial interest caused by company debt.

a. LOANS MADE BY THE BUSINESS: On a separate page, list any persons or businesses which have been loaned monies, equipment, or assets by this company. List the entity name, address, date of loan, amount or asset loaned, reason for such loan and loan status.

b. If this company is a subsidiary or intermediary company, list name and addresses of the officers, directors, and stockholders of each parent or intermediary company. If any parent or intermediary company is a publicly traded corporation, list the names and addresses of the officers, directors, and persons holding five percent (5%) or more of the publicly held securities of such company.

c. List each direct or indirect connection between this company and any person, firm, association, partnership or corporation licensed as a sales agent for Colorado Lottery products.

PERSON (VENDOR) RELATIONSHIP EMPLOYEE (LOTTERY)

9. GOVERNING BOARD MEMBERS AND CONTROL PERSONS WHO ARE OR HAVE BEEN COLORADO STATE EMPLOYEES

List all governing board members who are or have been Colorado State employees, showing their names, position or title, and state agency employer on a separate page.

a. If a CONTROL PERSON or subcontractor of the business, or any employee of either is assigned to a Colorado Lottery project, is an immediate family member of any lottery employee or commissioner, or has a close personal relationship to any lottery employee or commissioner, indicated each such person and lottery employee or commissioner.

11. CRIMINAL INVESTIGATIONS

Has the vendor, a subsidiary, company, intermediary company, parent company, holding company or any person identified in response to this disclosure statement ever been the subject of a GRAND JURY or CRIMINAL INVESTIGATION?

Yes [ ] No [ ]

If YES, provide complete details on attachment.

12. INDICTMENTS AND CONVICTIONS

Has the vendor, a subsidiary, company, intermediary company, parent company, holding company or any person identified in response to this disclosure statement ever been INDICTED, CHARGED or CONVICTED of any criminal offense?

Yes [ ] No [ ]

If YES, provide complete details on attachment.

13. JUDGMENTS OR DECREES

Has the vendor, a subsidiary, company, intermediary company, parent company, holding company, or any person identified in response to this disclosure statement been the subject of any disciplinary action, order, judgment or decree of any agency or court of competent jurisdiction permanently or temporarily censuring, revoking or suspending any license or enjoining it from, or otherwise limiting its participation in any type of business, practice or authority?

Yes [ ] No [ ]

If YES, provide complete details on attachment.

14. SUBSIDIARY AND INTERMEDIARY COMPANIES

On a separate page, list all subsidiary and intermediary companies including company name, address, business telephone, company head and description of the business or enterprise.

15. ANNUAL FINANCIAL STATEMENTS

Upon the request of the Security Director or Lottery Director, attach certified copies of the business FINANCIAL STATEMENTS for the past three (3) years as prepared by a certified public accountant.

Copies of the past three (3) years financial statements are attached.

Yes [ ] No [ ]

If NO, state reasons

16. REVENUE FROM STATES OPERATING LOTTERIES

State the gross receipts this company realized last year from the sale, lease or distribution of gaming materials or equipment to states operating lotteries.

17. REVENUE FROM PRIVATE PERSONS

State the gross receipts this company realized last year from the sale, lease or distribution of gaming materials or equipment to private persons licensed to conduct gambling.

18. SOURCES OF GAMING MATERIALS OR EQUIPMENT

State the name and addresses of this company’s sources of gaming materials or equipment.

19. NUMBER OF YEARS OF EXPERIENCE

State the number of years this company has been in the business of supplying gaming materials or equipment.

19a. Does your firm supply services to any firm involved in the gaming industry? If so, list the companies/clients.

20. BUSINESS ORGANIZATIONAL CHART

Attach a DIAGRAM of corporate ownership (refer to example) which depicts ownership of the vendor. Include all parent companies, holding companies, any interest holder of five percent (5%) or more and subsidiary companies.

An organizational chart depicting vendor owners and company structure is attached.

Yes [ ] No [ ]

EXAMPLE

S. Frank M. Dixon J. Johns

ACME Holding Co., Inc.

Widget Intl. John W. Smith

ABC, Inc.

XYZ Parts, Inc. D.E.F. Corp.

21. SWORN STATEMENT AND DEPOSITION

I, ______________________________________, being duly sworn, depose and say that I have read the above and attached statements, documents, information and diagram. That they are true and correct to the best of my knowledge and belief. Further, this statement is executed with the knowledge that misrepresentation made in the above disclosure may be deemed sufficient cause for the refusal by the Colorado Lottery to execute any contract or agreement. Further, that I am aware that later discovery of any omission or misrepresentation made in the above statements, documents, information and diagram may be grounds for the cancellation of an existing contract or agreement.

Printed Name Title

behalf of the vendor/company/applicant. That I hereby attest that the information provided is true, accurate and complete to the best of my knowledge.

Signature

Printed Name Title

Subscribed and sworn to before me this day of , 20 , at

Notary Public (Signature) My Commission Expires

INVESTIGATION AUTHORIZATION

AUTHORIZATION TO RELEASE INFORMATION

I, _________________________________, as authorized agent of the applicant, hereby authorize the Colorado Lottery Commission, the Lottery Division, the Colorado Bureau of Investigation and the Colorado Attorney General (hereafter, the Investigatory Agencies) to conduct a complete investigation into the background of the applicant business, using whatever legal means they deem appropriate. On behalf of the applicant, I hereby authorize any person or entity contacted by the Investigatory Agencies to provide any and all such information deemed necessary by the Investigatory Agencies. On behalf of the applicant, I hereby waive any rights of confidentiality in this regard.

I understand that by signing this authorization, a financial record check may be performed. On behalf of the applicant, I authorize any financial institution to surrender to the Investigatory Agencies a complete and accurate record of such transactions that may have occurred with that institution, including, but not limited to, internal banking memoranda, past and present loan applications, financial statements and any other documents relating to business financial records in whatever form and wherever located.

I understand that by signing this authorization on behalf of the applicant, a financial record check of the applicant’s tax filing and tax obligation status may be performed. I authorize any United States Department of Revenue to surrender to the Investigatory Agencies a complete and accurate record of any and all tax information or records relating to the applicant. I authorize the Investigatory Agencies to obtain, receive, review, copy, discuss and use any such tax information or documents relating to the applicant. I authorize the release of this type of information, even though such information may be designated as “confidential” or “nonpublic” under the provisions of state or federal laws.

The Investigatory Agencies reserve the right to investigate all relevant information and facts to their satisfaction. I understand that the Investigatory Agencies may conduct a complete and comprehensive investigation to determine the accuracy of all information gathered. However, the State of Colorado, Investigatory Agencies, and other agents or employees of the State of Colorado shall not be held liable for the receipt, use, or dissemination of inaccurate information. I, on behalf of the applicant, its legal representatives, and assigns, hereby release, waive, discharge, and agree to hold harmless, and otherwise waive liability as to the State of Colorado, Investigatory Agencies, and other agents or employees of the State of Colorado for any damages resulting from any use, disclosure, or publication in any manner, other than a willfully unlawful disclosure or publication, of any material or information acquired during inquiries, investigations, or hearings, and hereby authorize the lawful use, disclosure, or publication of this material or information.

Any information contained within the applicant’s application, contained within any financial or personnel record, or otherwise found, obtained, or maintained by the Investigatory Agencies, shall be accessible to law enforcement agents of this or any other state, the government of the United States, any foreign country, or any Indian Tribe.

A reproduction of this form by photocopying or similar process shall be for all intents and purposes as valid as the original.

Signature (Must be signed in front of Notary)

Subscribed and affirmed before me in the county of , State of , this day of , 20 .

Notary's Official Signature

Notary Seal

Commission expiration date

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