Attachment_Y_-_Campaign_Finance_Reform_Act_Self-Certification.pdf
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- Solicitation number
- DCAM-26-CS-RFP-0005
- Issued by
- District of Columbia
About this file
This is a Contractor Self-Certification form required by the District of Columbia Department of General Services for the Design-Build Services for Anacostia Recreation Center Pool Replacement project. The form implements compliance requirements under D.C. Law 22-250, the Campaign Finance Reform Amendment Act of 2018, and is mandatory for all contractors bidding on District of Columbia contracts. Contractors must disclose all political contributions made by the business entity or its principals to the Mayor, Attorney General, or any Councilmember since November 9, 2022, and must identify whether the business held any District contracts at the time such contributions were made or within one year prior. The form requires contractors to certify their business name, tax identification number, mailing address, and the names and titles of all company principals, defined as senior officers with authority to influence overall business strategy.
Contractors must affirmatively certify that the business entity is not currently in violation of D.C. Official Code § 1-1163.34a and will not become in violation of this statute. The form requires disclosure of any prior determinations of violations and their resolutions. All information provided must be accurate, complete, and continuously maintained throughout the contract term. The certification must be sworn before a notary public and signed by an authorized representative of the contractor. Designated modifiers must be identified who are authorized to update the certification on behalf of the business entity.
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V004/09.12.2024
CONTRACTOR SELF-CERTIFICATION
Business Name* : Tax ID* :
Business Mailing Address * :
Select State/Region: Postal Code:
List the name and title of the individual completing the form on behalf of the business. Business Title * :
Name * :
Email * :
D.C. Law 22-250. Campaign Finance Reform Amendment Act of 2018. | D.C. Law Library (dccouncil.gov)
Since November 9, 2022, has the business entity or any of its Principals made a political contribution to any of the following: (i) the Mayor, (ii) any candidate for Mayor, (iii) any political committee affiliated with the Mayor or a candidate for Mayor, or (iv) any constituent-service program affiliated with the Mayor? [yes/no]
If yes, please provide the following information (for each contribution):
Date of contribution:
Amount of contribution:
Recipient of contribution:
Did the business entity hold any District contracts at the time the contribution was made or within one (1) year prior to the date the contribution was made? If yes, please provide award date and duration of the contract(s).
Since November 9, 2022, has the business entity or any of its Principals made a political contribution to any of the following: (i) the Attorney General, (ii) any candidate for Attorney General, or (iii) any political committee affiliated with the Attorney General or a candidate for Attorney General? [yes/no]
If yes, provide the following information (for each contribution):
Amount of contribution:
Recipient of contribution:
Did the business entity hold any District contracts at the time the contribution was made or within one (1) year prior to the date the contribution was made? If yes, please provide award date and duration of the contract(s).
Since November 9, 2022, has the business entity or any of its Principals made a political contribution to any of the following: (i) any Councilmember, (ii) any candidate for Councilmember, (iii) any political committee affiliated with a Councilmember or a candidate for Councilmember, or (iv) any constituent-service program affiliated with a Council member? [yes/no]
If yes, provide the following information (for each contribution):
Amount of contribution:
Recipient of contribution:
Did the business entity hold any District contracts at the time the contribution was made or within one (1) year prior to the date the contribution was made? If yes, please provide award date and duration of the contract(s).
Prior to the date of this Certification, has the business entity been determined to be in violation of D.C. Official Code § 1-1163.34a? [yes/no]
If yes, please explain including any resolution.
Is the business entity currently in violation of D.C. Official Code § 1-1163.34a? [yes/no]
If yes, please explain including any resolution.
Does the business entity certify that it will not be in violation of D.C. Official Code § 1-1163.34a? [yes/no]
“Principal” – any senior officer of a business entity, including an owner or co-owner, president, chief executive officer, chief operating officer, chief financial officer, treasurer, member, partner, or similar position which either sets or is authorized to set or otherwise influences the overall strategy of the business entity. A dean of an educational institution is not a “principal” within the meaning of this definition. A person whose only position at the business entity is as a board member is not a “principal” within the meaning of this definition.
Provide the names and titles of all the company principals (use additional sheets if required).
1.
2.
Who else will modify this certification for the business?
Modifier 1:
Modifier 2:
Check to certify that the information is accurate and complete. *
Check to acknowledge that the business must always keep these records updated*
Check to certify that the business entity currently is not and will not be in violation of the Campaign Finance Reform Amendment Act of 2018 *
On behalf of the Contractor:
Name & Signature
Sworn to this before me this _day of _20
Date
Notary Public My Commission Expires
File details come from the government source that posted it. Updated .