Attachment_Y_-_Campaign_Finance_Reform_Act_Self-Certification.pdf
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- Solicitation number
- DCAM-26-CS-RFP-0006
- Issued by
- District of Columbia
About this file
This is a Contractor Self-Certification form issued by the District of Columbia Department of General Services' Contracts & Procurement division for the Design-Build Services for the New River Terrace Recreation Center project located in Ward 7 at 500 36th Street NE, Washington, DC 20019. The form requires contractors to provide business identification information, including business name, Tax ID, mailing address, and the name and title of the individual completing the certification on behalf of the business. Contractors must disclose all political contributions made by the business entity or its principals since November 9, 2022, to the Mayor, candidates for Mayor, affiliated political committees, Attorney General, candidates for Attorney General, Councilmembers, candidates for Councilmembers, and affiliated constituent-service programs. For each disclosed contribution, contractors must provide the date, amount, and recipient, and identify any District contracts held at the time of contribution or within one year prior.
The certification requires contractors to confirm whether the business or any principal has been determined to be in violation of D.C. Official Code § 1-1163.34a and whether the business is currently in violation of that code. Contractors must also identify all company principals, defined as senior officers including owners, co-owners, presidents, chief executive officers, chief operating officers, chief financial officers, treasurers, members, and partners who set or influence the overall strategy of the business entity. The form must be completed accurately and kept current by the contractor, sworn before a notary public, and certified to confirm that the business entity currently is not and will not be in violation of the Campaign Finance Reform Amendment Act of 2018.
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Text version
V004/09.12.2024
Contracts & Procurement
Department of General Services 3924 Minnesota Avenue, NE, Washington D.C. 20019
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
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