Attachment B Certification Statement~31.pdf

ATTACHMENT B

CERTIFICATION STATEMENT

Certification of Compliance with Massachusetts Child Care Law Pursuant to Chapter 521 of the Massachusetts Acts of 1990, as amended by Chapter 329 of the Acts of 1991, the undersigned certifies that the firm (please check applicable item):

1.) _____ employs fewer than fifty (50) full-time employees: or 2.) _____ offers either a dependent care assistance program or a cafeteria plan whose benefits include a dependent care assistance program; or 3.) _____ offers childcare tuition assistance, or on-site or near-site subsidized childcare placements.

Certification of Compliance with the Revenue Enforcement and Protection Program Pursuant to M.G.L. Chapter 62C, the undersigned certifies under penalties of perjury that the firm (check applicable item):

1.) _____ has filed and paid all taxes required by law; or 2.) _____ has filed a pending application for abatement of such tax; or 3.) _____ has a petition before the appellate tax board contesting such tax; or 4.) _____ does not derive taxable income from Massachusetts sources such that it is subject to taxation by the Commonwealth.

Certificate Regarding Companies Doing Business in Northern Ireland Pursuant to M.G.L. Chapter 7, the undersigned hereby certifies under penalties of perjury that the firm is not engaged in the manufacture, distribution or sale of firearms, munitions, including rubber bullets, tear gas, armored vehicles or military aircraft for use or deployment in any activity in Northern Ireland, and the firm (check applicable item):

1.) _____ does not employ ten or more employees in an office or other facility located in Northern Ireland; or

2.) _____ employs ten or more employees in an office or other facility located in Northern Ireland, but such office or other facility located in Northern Ireland (a) does not discriminate in employment, compensation, or the terms, conditions and privileges of employment on account of religious or political belief; and (b) promotes religious tolerance within the work place, and the eradication of any manifestations of religious and other illegal discrimination.

Certification of Disclosure (Respondents must answer each of the following questions.

Attach separate pages as needed.)

1.) State your firm’s name and address.

2.) State the name and position of the officer completing this disclosure statement.

3.) Describe your firm’s organizational structure (e.g. partnerships, corporation, etc.)

and list any controlling stockholders, general partners or principals. Also list any subsidiaries, joint ventures, consultants, lobbyists, subcontractors or agents that have relationships with your firm and relate in any way to your proposed business with the MSBA.

4.) Did your firm or will your firm, its related entities or any individual listed in response to question 3 above, provide, agree to provide or arrange to provide any compensation or benefit, direct or indirect to any individual or entity, including without limitation, lobbyists, consultants or agents, whether related or unrelated to your firm, for their services in your firm’s obtaining its engagement for the provision of services to the MSBA? If the answer is “Yes”, please provide the name and address of such individual or entity and a description of the services performed by them and the compensation or benefit.

5.) Has your firm, its related entities or any individual listed in response to question 3 above, shared any fees with any person or entity, whether related or unrelated, with respect to your firm’s proposed engagements for services with the MSBA?

If so, please describe such arrangements whether or not any fees have actually been shared.

6.) Does your firm, its related entities or any individual listed in question 3 above, have any on-going arrangement with any related or unrelated individual or entity with respect to sharing fees that would be received from services provided to the MSBA? If so, please describe such arrangements.

7.) Does your firm have any arrangements, agreements or relationships similar to those listed in questions 3-6 above for business related to any other issuer of tax-exempt bonds or notes within the Commonwealth? If so, please describe the nature of those arrangements.

8.) If selected pursuant to this RFQ to which this statement is attached, please certify that your firm will disclose promptly, in writing, all future relationships like those described above.

Certification of No Conflicting Relationship The undersigned certifies under penalties of perjury that no relationship which would constitute a violation of any Massachusetts general or special law regarding a state public official or their immediate family exists, and that no relationship exists which interferes with fair competition with respect to its Response.

Certificate Statement Regarding Criminal Actions and Pending Litigation The Respondent shall provide a written statement as to the status of any pertinent judgment, criminal action, investigation or litigation under federal law or by any state against the Respondent or registered principals of the responding firm within the year preceding the date of your response or a statement that there are none.

Certification of Good Standing and Licensure The undersigned certifies under penalties of perjury that all personnel who may provide services under this RFR meet all applicable state and federal requirements, have all the licenses and registrations necessary to perform the contract, and are in good standing in each state licensed.

Certification of Solvency The undersigned certifies under penalties of perjury that the Respondent has not been in bankruptcy and/or receivership within the last three calendar years.

Certification of Minimum Qualifications The undersigned certifies that the Respondent meets the minimum qualifications of Section V of this RFR.

Statement of Compliance with RFR Requirements The undersigned agrees to meet every specification, requirement, or condition set forth in the RFR. This statement will not be deemed to encompass any requirement, specification or condition for which the RFR indicates that a preference may or will be given by the MSBA. Any such requirement, specification, or condition must be met only by a Respondent seeking the preference.

Statement of Confidentiality The undersigned acknowledges that all materials and information provided to the undersigned by the MSBA or acquired by the undersigned on behalf of the MSBA shall be regarded as confidential information in accordance with Federal and State law and ethical standards. The undersigned agrees to take all necessary steps to safeguard the confidentiality of such materials or information. Furthermore, the undersigned agrees to execute a Non-Disclosure Agreement and acknowledges that the MSBA may require the undersigned’s support staff or outside vendors to sign a Non-Disclosure Agreement that covers the confidential information they will have or have access to.

Signed this _____ day of ____________, 20____.

Name of Firm: _____________________________________________________

Authorized Signature: _________________________________________ Title: _______________________________________________________