Attachment C - Annual Affidavit and Other Affidavits- RFP 758 2700000097.pdf

Rev. 9-16-22 Required Affidavit for Bidders, Offerors and Contractors

(KRS 45A.110 & 45A.115)

Affidavit Effective for One (1) Year from Date of Execution

Instructions: Pursuant to KRS 45A.110 and 45A.115, a bidder, offeror, or contractor (“Contractor”) is required to submit a Required Affidavit for Bidders, Offerors, and Contractors to be awarded a contract, or for the renewal of a contract. An authorized representative of the contracting party must complete the attestation below, have the attestation notarized, and return the completed affidavit to the Commonwealth.

Attestation

As a duly authorized representative for the Contractor, I swear and affirm under penalty of perjury, that that the Contractor has not knowingly violated campaign finance laws of the Commonwealth of Kentucky and that the award of a contract will not violate any provision of the campaign finance laws of the Commonwealth. For purposes of this attestation, "Knowingly" means that the bidder or offeror is aware or should have been aware of the existence of a violation. The bidder or offer understands that the Commonwealth retains the right to request an updated affidavit at any time.

Signature Printed Name

Title Date

Bidder or Offeror Name: __________________________________________________________

Address: __________________________________________________________

Commonwealth of Kentucky Vendor Code (If known): _______________

Subscribed and sworn to before me this _____ day of _______________, ____________.

State of: ___________________ Notary: ___________________________________

County of: _________________ My Commission Expires: _____________________

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS CLAIMING RESIDENT BIDER

STATUS

FOR BIDS AND CONTRACTS IN GENERAL:

The bidder or offeror hereby swears and affirms under penalty of perjury that, in accordance with KRS 45A.494(2), the entity bidding is an individual, partnership, association, corporation, or other business entity that, on the date the contract is first advertised or announced as available for bidding:

1. Is authorized to transact business in the Commonwealth;

2. Has for one year prior to and through the date of advertisement

a. Filed Kentucky corporate income taxes;

b. Made payments to the Kentucky unemployment insurance fund established in KRS 341.490; and

c. Maintained a Kentucky workers’ compensation policy in effect.

The BIDDING AGENCY reserves the right to request documentation supporting a bidder’s claim of resident bidder status.

Failure to provide such documentation upon request shall result in disqualification of the bidder or contract termination.

Signature Printed Name

Title Date

Company Name Address

Subscribed and sworn to before me by

(Affiant) (Title) of this _____day of ____________, 20___.

(Company Name)

Notary Public

[seal of notary] My commission expires:

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS CLAIMING QUALIFIED BIDDER

STATUS

FOR BIDS AND CONTRACTS IN GENERAL:

I. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding, and all subcontractors therein, meets the requirements to be considered a “qualified bidder” in accordance with 200 KAR 5:410(3); and will continue to comply with such requirements for the duration of any contract awarded. Please identify below the particular “qualified bidder” status claimed by the bidding entity.

________ A nonprofit corporation that furthers the purposes of KRS Chapter 163

________ Per KRS 45A.465(3), a "Qualified nonprofit agency for individuals with severe disabilities" means an organization that:

(a) Is organized and operated in the interest of individuals with severe disabilities; and

(b) Complies with any applicable occupational health and safety law of the United States and the Commonwealth; and

(c) In the manufacture or provision of products or services listed or purchased under KRS 45A.470, during the fiscal year employs individuals with severe disabilities for not less than seventy-five percent (75%) of the man hours of direct labor required for the manufacture or provision of the products or services; and

(d) Is registered and in good standing as a nonprofit organization with the Secretary of State.

The BIDDING AGENCY reserves the right to request documentation supporting a bidder’s claim of qualified bidder status.

Failure to provide such documentation upon request may result in disqualification of the bidder or contract termination.

Signature Printed Name

Title Date

Company Name Address

Subscribed and sworn to before me by (Affiant) (Title) of this _____day of ____________, 20___.

(Company Name)

Notary Public

[seal of notary] My commission expires: