Attachment E - Affidavits-Forms.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 BIDDER 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 income taxes;

b. Made payments to the Kentucky unemployment insurance fund established in KRS 341.49; 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:

VENDOR REPORT OF PRIOR VIOLATIONS

ON CONSTRUCTION SEALED BIDS

This form is applicable to all sealed bids for construction projects issued by the Finance and Administration Cabinet, Division of Engineering and Contract Administration (DECA) in accordance with KRS 45A.080.

The Prime Bidder on any construction sealed bid shall provide the required information attached, for the Prime Bidder, as an attachment to the bid.

The information required is specifically - any violations issued within the last five (5) calendar years of the following:

1. Violations of KRS Chapter 136 (Corporation and Utility Taxes);

2. Violations of KRS Chapter 139 (Sales and Use Taxes);

3. Violations of KRS Chapter 141 (Income Taxes);

4. Violations of KRS Chapter 337 (Wages and Hours);

5. Violations of KRS Chapter 338 (Occupational Safety and Health of Employees);

6. Violations of KRS Chapter 341 (Unemployment Insurance);

7. Violations of KRS Chapter 342 (Workers Compensation); and

8. Violations of Occupational Safety and Health Laws in any other states and at the federal level.

If there are no violations for a particular category, vendor should attach a statement to that effect.

If there are violations for a particular category, the vendor should list them and provide the following information for each: the date of the violation, a short description of the violation (including statutory citation), the name of the governmental enforcement agency involved, and the amount of any penalties imposed as a result of the final determination.

Please note that this information may be provided to other governmental agencies, such as the Kentucky Labor Cabinet, as part of the bid process. DECA reserves the unqualified right to disqualify any vendors from participating further in this bid process.

In addition, the successful prime bidder and subcontractors shall remain in continuous compliance with KRS 45A.485 during the life of any contract awarded, and shall notify DECA of any new final determinations of violations in any of the above-mentioned categories, which occur after contract award, and during the life of any contract awarded. Failure to comply with these requirements may result in the bidder and subcontractors being disqualified from participating in future bid opportunities for the Commonwealth.

COMPANY NAME: ____________________________________________

TAX PAYER ID #: ____________________________________________

THIS VENDOR VIOLATION FORM MAY BE SENT TO THE LABOR CABINET FOR VERIFICATION. PLEASE MAKE SURE ALL YOUR VIOLATIONS ISSUED WITHIN THE LAST FIVE (5) YEARS ARE LISTED. IF YOU LIST “NONE” BUT THE LABOR CABINET’S RECORDS SHOW OTHERWISE, YOUR BID MAY BE REJECTED. FOR A LIST OF YOUR VENDOR

VIOLATIONS, YOU CAN FAX OR EMAIL THE LABOR CABINET WITH YOUR REQUEST.

FAX NUMBER IS (502) 696-1984 OR EMAIL: wages@ky.gov .

Violation Category Date Description Govt. Enforcement Agency

Amount of Penalties