Attachment G Vendor Disclosure Statement.docx
DOCX document 28 KB Posted
- Solicitation number
- RFP IHGA 2017000139 4
- Issued by
- Denver County, Denver City, Colorado
About this file
This is a Vendor Disclosure Statement form required by Colorado Revised Statutes 24-102-206 for prospective vendors seeking to contract with the State of Colorado or institutions of higher education (IHEs). The form requires vendors to disclose information regarding contract performance locations prior to solicitation or contracting. The disclosure statement applies to all service contracts unless specifically exempted, including those under Medicare, the Colorado Medical Assistance Act, the Children's Basic Health Plan Act, or the Colorado Indigent Care Program. Construction contracts are not subject to this disclosure requirement.
The vendor must complete three primary sections: providing the solicitation or contract routing number and identifying both the vendor name and contracting state agency or IHE; listing all countries and states where contract services, including any subcontract work, will be performed; and, if services will be performed outside the United States or Colorado, explaining the necessity or advantage of performing work in those external locations. The completed statement must be signed and dated by an authorized representative with their printed name and title included.
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Text version
Attachment G
Vendor Disclosure Statement Colorado Revised Statutes § 24-102-206
Contract Performance Outside of the United States or Colorado
Prior to contracting, or as a requirement for the solicitation of any contract for services from the State of Colorado, a prospective vendor is required to disclose the following information in a statement of work.
Completing this Form
· To the extent the following information has not previously disclosed in a statement of work, a prospective vendor shall complete this Vendor Disclosure Statement and return it to the contracting state agency or institution of higher education (IHE).
· This Disclosure Statement is not required for contracts under Medicare, the “Colorado Medical Assistance Act”, Articles 4 to 6 of Title 25.5, CRS, the “Children’s Basic Health Plan Act”, Article 8 of Title 25.5, CRS, or the “Colorado Indigent Care Program”, Part I of Article 3 of Title 25.5, CRS.
· This Disclosure Statement is not required for Construction contracts.
1. Solicitation or Contract Routing Number: 17 IHGA
Vendor Name: Click here to enter text.
State Agency/IHE Name: Click here to enter text.
2. Where will the services under the contract, including any subcontracts, be performed? List all country(ies) and state(s). Click here to enter text.
3. If it is anticipated that services under the contract, or any subcontracts, will be performed outside of the United States or the State of Colorado, explain why it is necessary or advantageous to go outside the United States or the State of Colorado to perform the contract or any subcontracts. Click here to enter text.
| ______________________________ | _____________ | |
| Signature | Date |
| _______________________________ | _____________ | |
| Printed Name | Title |
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