Attachment_12_Major_Procurement_Vendor_Disclosure_Final.pdf

Major Procurement Vendor Disclosure

Oregon State Lottery

Investigations Conducted by Revised November 2025 Oregon State Police Confidential Gaming Enforcement Division

Name of Business Entity:_______________________________________________________________ Address:____________________________________________________________________________ Contact Person:______________________________________________________________________ Telephone Number:___________________________________________________________________

Read every question carefully prior to responding. Answer every question completely.

All entries on this form must be typed or neatly printed except for signatures.

If a question does not apply, so state with N/A in the response to that question. If there is nothing to disclose as to a particular question, state “None” in response to that question.

If space available is insufficient, continue on a separate sheet and precede each answer with the appropriate title and section number.

The applicant company president, CEO, or company representative must initial each page as provided in lower right-hand corner. The applicant is attesting to the accuracy and completeness of the information contained on that page.

All applicants are advised that this Vendor Disclosure is an official document and misrepresentation or failure to reveal information requested may be deemed to be sufficient cause for the refusal or revocation of a contract or agreement and cause for possible criminal prosecution.

Return the completed Procurement Disclosure Form (original) to the Oregon State Lottery, Assistant Director for Security, 500 Airport Road, SE, Salem, OR 97301.

Applicant’s Initial_____

GENERAL INSTRUCTIONS

MAJOR PROCUREMENT DISCLOSURE

INFORMATION FORM

1. Name of Business_____________________________________________________________________ Trade name/doing business as:__________________________________________________________ Address of business entity:______________________________________________________________ (Street) (City) (State) (Zip)

Telephone Number:__________________________________

Type of business entity: □ Sole proprietorship □ Corporation □ Trust

□ Partnership □ Joint venture □ Other________________________

State of incorporation/establishment:______________Date of incorporation/establishment:___________

Provide a certified copy of Articles of Incorporation/Partnership Agreement.

Federal Tax Number (or foreign equivalent):__________________________________

List other states or jurisdictions where incorporated or filed with State Corporations Division:__________

List the services or supplies your business provides:

Name of parent company:_______________________________________________________________ Address of parent company:_____________________________________________________________

Name(s) and address(es) of any subsidiary or affiliate of the business:

Name Street City State Zip

Provide an organization chart of the business showing its relationship to existing parent, subsidiary or affiliated companies.

Is this business entity stock: □ Privately held □ Publicly held

SECTION 1

BUSINESS ENTITY

2. List all CONTROL PERSONS (corporate officers, directors, partners, members, key employees, and management contractors). Also list all STOCKHOLDERS owning 15% or more interest in this company.

List full name, title, residence address, date of birth, and social security number.

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Name (Last) (First) (MI) Title DOB

Address City/State/Zip SSN

Provide a Personal Disclosure form for each control person.

3. Are there any Officers, Directors, Partners, Members, Stockholders (15% or more) or Key Employees who are actively involved in this vendor’s day-to-day operation as it relates to the Oregon Lottery?

□ Yes □ No

If Yes, provide their names and addresses:

4. List the Business’s Certified Public Accountants:

Internal: External:

Name:__________________________________ Name: ___________________________________ Address:________________________________ Address: _________________________________

Telephone Number:_______________________ Telephone Number:_________________________

5. Has this company ever held or does it now hold any gambling or gaming licenses or permits in any jurisdiction? □ Yes □ No

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.

6. Has a gaming license or permit for this company ever been denied, revoked or suspended?

If Yes, provide complete details on a separate page.

7. Has this company ever been fined by any gaming authority for any reason within the past three years?

□ Yes □ No If Yes, provide complete details on a separate page.

8. Has this company ever withdrawn an application for a gaming license? □ Yes □ No

If Yes, provide complete details on a separate page.

9. List locations where your company contracts to supply gaming goods or services and to whom those goods or services are provided, on a separate page.

10. List all governing board members who are or have been Oregon State employees, showing their names, position or title, and state agency employer on a separate page. □ None

11. If a CONTROL PERSON or subcontractor of the business, or any employee of either, assigned to an Oregon

Lottery project, is an immediate family member of any Lottery employee, or has a close personal relationship to any Lottery employee, indicate each such person and Lottery employee:

Person (Vendor) Relationship Employee (Lottery)

For any questions answered “Yes” in this section, provide complete details on a separate page.

1. Has the vendor, a subsidiary or intermediary company, parent company, or holding company, or related corporation or business entity ever been the subject of a GRAND JURY or CRIMINAL INVESTIGATION?

2. Has the vendor, a subsidiary or intermediary company, parent company, or holding company, related corporation or business entity, or any key person in any of the preceding ever:

Been convicted at any time of any crime? □ Yes □ No Been convicted of violating any of the gambling laws of any state, county or local municipality?

Are there any Class “A” misdemeanor or felony charges pending? □ Yes □ No

3. Has the vendor, a subsidiary or intermediary company, parent company, holding company, related corporation, or business entity, or any key person in any of the preceding ever been involved in any civil lawsuit? □ Yes □ No

4. Were any of the lawsuits referenced above predicated in whole or in part upon conduct which allegedly constituted a crime or crimes? □ Yes □ No

5. Has the business or its officers or directors ever been the subject of antitrust violation allegations, trade regulation allegations, security judgments, or insolvency proceedings within the last 5 years?

6. Has the company ever been investigated for violating any tax laws, either civil or criminal?

7. Is the company aware of any tax liens against it? □ Yes □ No

8. List all attorneys and law firms representing your company in the State of Oregon, including address and phone numbers.

Name Address Phone Number

SECTION 2

LEGAL PROCEEDINGS

1. Has the business been deemed legally bankrupt or filed a petition for any type of bankruptcy or insolvency, under any bankruptcy or insolvency law, within the last 7 years? □ Yes □ No

If Yes, provide details including date filed, docket number, name and address of court, name and address of filing party, and name and address of trustee on a separate page.

2. Provide audited FINANCIAL STATEMENTS for the past three (3) years as prepared by a certified public accountant.

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

4. Is the business or property □ owned, □ rented, □ leased, or □ other, by the applicant? List the mortgage holder (if owned) including the terms of the mortgage and attach a copy of the contract. If the location is rented or leased, list the lessor, or owner and provide a copy of the rental or lease agreement. Include the property owner’s name, address, and phone number.

1. Copy of Articles of Incorporation/Partnership Agreement. □ Attached

2. Organization chart of the business showing its relationship to existing parent, subsidiary or affiliated companies. □ Attached

3. Personal Disclosure form for each control person. □ Attached

4. List of gambling or gaming licenses or permits. □ Attached

5. Explanations for gaming license denials, suspensions, revocations, withdrawals, and fines. □ Attached

6. List of all locations where company is contracting to provide gaming goods and services, and to whom they are provided. □ Attached

7. Summary of past and current litigation including case number, date, courts, all parties, subject matter, and disposition. □ Attached

SECTION 3

FINANCIAL DATA

SECTION 4

REQUIRED ATTACHMENTS

8. Financial statements for past three years. If financial statements are unaudited, also include federal tax filings for past three years. □ Attached

9. List of lien and interest holders. □ Attached

10. Minutes of last three years of Board of Directors and Shareholders meetings. □ Attached

11. All current real property lease summary agreements. □ Attached

AUTHORITY TO RELEASE CREDIT,

CHARACTER, AND VENDOR HISTORY INFORMATION

Having made application through the Oregon State Lottery, I hereby authorize a complete investigation of the vendor, including vendor history, credit record, civil litigation, business records, corporate records history, corporate filings, banking records, and criminal arrest and indictments, by the Oregon State Police, or another police agency authorized to conduct applicant investigations to ascertain any and all information which may concern vendor credit, character, or history, whether same is of record or not, and release your organization and all persons whomsoever from any charge because of furnishing said information. I authorize a true copy of the original of this authorization as if the copy were the original itself.

NOTICE TO APPLICANT:

I understand that pursuant to ORS 192.593(2)(d), I may revoke this authorization at any time in writing.

Any such revocation shall be sent to the Oregon State Lottery, Assistant Director for Security, 500 Airport Road, SE, Salem, OR 97301, by certified mail, return receipt requested.

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

Business Name (Please Print)

Name (Company President/CEO, Corporate Officer)

Signature Date

Telephone

FINANCIAL RECORDS DISCLOSURE AUTHORIZATION

TO ANY FINANCIAL INSTITUTION:

I authorize and direct you to disclose any and all records and to deliver true copies thereof concerning or pertaining in any way to me or to the undersigned business to any law enforcement officer of the Oregon State Police, Gaming Enforcement Division. Disclosure is authorized for any civil, administrative, or criminal action which may be undertaken by the State of Oregon against me or any other person or business.

Further, I authorize and direct you to honor a true copy of the original of this authorization as if the copy were the original itself.

NOTICE TO APPLICANT:

I understand that pursuant to ORS 192.593(2)(d), I may revoke this authorization at any time in writing.

Any such revocation shall be sent to the Oregon State Lottery, Assistant Director for Security, 500 Airport Road, SE, Salem, Oregon 97301, certified mail, return receipt requested.

EXCUTED this _______ day of ___________________, 20___.

Applicant’s Signature

Print Name

Applicant’s Title

SWORN STATEMENT AND DEPOSITION

State of________________) ) ss.

County of_______________)

I, __________________________________, being duly sworn, depose and say that I have read the above and attached statements, documents, information, and organizational chart, and that they are true and correct to the best of my knowledge and belief. Further, this statement is executed with the knowledge that misrepresentation or failure to disclose made in the above disclosure may be deemed sufficient cause for the refusal by the Oregon State Lottery to execute any contract or agreement. Further, that I am aware that later discovery of an omission or misrepresentation made in the above statements, documents, information, and organizational chart may be grounds for the cancellation of an existing contract or agreement. Further, that I am voluntarily submitting this disclosure under oath with the full knowledge that Oregon Revised Statute 162.075, False Swearing, provides that, “(1) A person commits the crime of false swearing if the person makes a false sworn statement, knowing it to be false, and (2) False Swearing is a Class A Misdemeanor.”

Company President/CEO_______________________________________ Signature Printed Name Title

I,________________________________, do hereby certify that I have prepared this document on Representative’s Name 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 Business Address: _______________________________________ Telephone Number: _______________________

Applicant’s Initial____