Attachment E.pdf

AOC-PRO-19

Rev. 8-22 Commonwealth of Kentucky Court of Justice www.kycourts.gov

AOC.005 Procurement of Goods and Services

VENDOR DISCLOSURE OF

OWNERSHIP

l e x e t j u s t i t i a

CO

M

MONWEALTH OF KENTUCKY

C O

U R T O F J U

S T I

C E

PROCUREMENT USE ONLY

PO/ DO/ Contract #: __________________

Received Date: ______________________

Received By: ________________________

Vendor Status: New Current

SECTION 1: Vendor Information Vendor Name: ____________________________________________________________________________

Vendor Representative Name: ___________________________ Title: ____________________________________

Phone: (____) _____- ________ Email: ________________________________ Federal Tax ID: ______________

Mailing Address: _________________________ City: _________________ State: ____ Zip: ___________

Website Address: _________________________________________________________________________

Vendor is organized as a:

Individual (Sole Proprietorship) General Partnership Limited Partnership (LP)

Business Corporation Professional Service Corporation Joint Venture

Limited Liability Company (LLC) Professional Limited Liability Company (PLLC) Business Trust

Non-Profit Corporation Non-Profit Limited Liability Company Other: _________________

Is the owner registered to do business in Kentucky? Yes No Not applicable

If no, does the owner have a Kentucky certificate of authority (COA)? Yes No If yes, attach the COA.

SECTION 2: Ownership Interests and Income Beneficiaries

(1) If the vendor is organized as anything other than a sole proprietorship, list the names of all individuals holding

5% or more interest in the entity.

Name: ________________________________ Position Held: ________________________________ Name: ________________________________ Position Held: ________________________________ Name: ________________________________ Position Held: ________________________________

(2) If the vendor would receive income from the sale of commodities or services to the Kentucky Court of Justice (KCOJ) and then, by way of assignment, transfer, or any other direct or indirect means, conveys some part of that income to any person, identify below each recipient of the income and the amounts received:

Name: ________________________________ Amount Received: $ _______________ Name: ________________________________ Amount Received: $ _______________ Name: ________________________________ Amount Received: $ _______________

(3) List below the names of any person identified in Section 2(1) and/or (2) above who are either:

(a) An appointed KCOJ official; or

(b) An elected KCOJ official; or

(c) A KCOJ employee; or

(d) A family member of an appointed or elected KCOJ official or employee. A family member means an individual’s spouse, child, parent, grandparent, grandchild, brother, or sister, or person of similarly close relationship defined as: (a) an intimate partner who has resided with the individual for at least one year;

or (b) one for whom the individual is legally responsible.

Attachment E

AOC-PRO-19

Rev. 8-22

Name: Relationship: _______________________________________ Name: Relationship: _______________________________________ Name: Relationship: _______________________________________

SECTION 3: Agreements and Certifications

(1) If awarded a contract or purchase order, the vendor agrees to notify the Administrative Office of the Courts

(AOC), Department of Financial Services, Division of Procurement by submitting a new AOC-PRO-19 Vendor Disclosure of Ownership form when there is a change in (a) ownership of the vendor; or (b) to the persons required to be identified in Section 2 above. Noncompliance may result in immediate cancellation of the contract. The Division of Procurement may be contacted via email at Procurement@kycourts.net or by phone at (502) 573-2350.

(2) The undersigned hereby certifies that neither the undersigned, nor any entity which the undersigned owns, has contributed more than the amount specified in KRS 121.150 to the campaign of any KCOJ official. The undersigned further swears, under the penalty of perjury, that neither he/she nor the entity which he/she represents has knowingly violated any provisions of the campaign finance laws of the Commonwealth of Kentucky, and that the award of a contract to him/her or the entity which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth of Kentucky.

(3) The undersigned hereby swears that he/she is neither an appointed or elected official in the KCOJ nor otherwise employed by the KCOJ. The undersigned also swears that he/she is not a family member of a KCOJ employee or of an appointed or elected official as defined in Section 2(3)(d) above.

(4) To the best knowledge and belief of the undersigned, neither the vendor nor any of its principals are presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any State or Federal agency.

(5) If awarded a contract, the vendor agrees to comply in full with the requirements of the Kentucky Civil Rights Act, and agrees to timely submit any data requested by the AOC.

Owner/ Representative Signature: _______________________________________________

Title: _______________________________________________ Date: _______________

State of _________________________ )

) SS

County of ________________________ )

The foregoing statement was acknowledged and sworn to before me this _____ day of ________________, 20_____ by __________________________________________.

Notary Public My Commission Expires: _____________ mailto:Procurement%40kycourts.net?subject=