Attachment C - Bidders Disclosure of Prior Non-Responsibility Determinations.pdf
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- Solicitation number
- 2140589
- Issued by
- New York
About this file
This is a Bidder's Disclosure of Prior Non-Responsibility Determinations form (AF 11, dated 6-06) used by a governmental entity to evaluate bidder responsibility and compliance in a procurement process. The form requires bidders to disclose any prior findings of non-responsibility made against the individual or entity seeking to enter into a procurement contract within the previous four years. Bidders must provide their name, address, the name and title of the person submitting the form, and the contract procurement number, along with the submission date.
The form contains six disclosure questions addressing critical compliance areas: whether any governmental entity has made a prior non-responsibility finding; whether such findings were based on violations of State Finance Law 139-j; whether findings resulted from intentional provision of false or incomplete information to a governmental entity; detailed information regarding any such findings, including the governmental entity involved, date of finding, and basis; whether any governmental entity has terminated or withheld a procurement contract due to intentional provision of false or incomplete information; and detailed information regarding any contract terminations or withholdings. Bidders must certify that all information provided regarding State Finance Law 139-k compliance is complete, true, and accurate, with the form requiring an authorized signature, printed name, title, and date of certification.
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Text version
AF 11 (6-06)
Attachment C
Bidder’s Disclosure of Prior Non-Responsibility Determinations
Name of Individual or Entity Seeking to Enter into the Procurement Contract:
Address: _______________________________________________________________
Name and Title of Person Submitting this Form: ________________________________
Contract Procurement Number: _____________________________________________
Date:________________________
1. Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years? (Please circle):
No Yes
If yes, please answer the next questions:
2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law §139-j (Please circle):
3. Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Governmental Entity? (Please circle):
4. If you answered yes to any of the above questions, please provide details regarding the finding of non-responsibility below.
Governmental Entity: ___________________________________________________________
Date of Finding of Non-responsibility: ______________________________________________
Basis of Finding of Non-Responsibility: _____________________________________________
(Add additional pages as necessary)
AF 11 (6-06)
5. Has any Governmental Entity or other governmental agency terminated or withheld a Procurement Contract with the above-named individual or entity due to the intentional provision of false or incomplete information? (Please circle):
6. If yes, please provide details below.
Governmental Entity: ______________________________________________
Date of Termination or Withholding of Contract: _______________________________________
Basis of Termination or Withholding: ____________________________________________
(Add additional pages as necessary)
Offerer certifies that all information provided to the Governmental Entity with respect to State
Finance Law §139-k is complete, true and accurate.
By: Date:
Signature
Name:
Title:
File details come from the government source that posted it. Updated .