Campaign_Finance_Reform_Act_Self-Certification_Form.pdf
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- Solicitation number
- DCAM-22-CS-RFQ-0001 - RFTOP-CS-0179
- Issued by
- District of Columbia
About this file
This is a Campaign Finance Reform Act Contractor Self-Certification Form issued by the District of Columbia Department of General Services, applicable to the Cardozo Education Campus HVAC Upgrades project (canceled). The form requires contractors to disclose all political contributions made since November 9, 2022, to the Mayor, any mayoral candidates, affiliated political committees, constituent-service programs, the Attorney General, any Attorney General candidates, affiliated political committees, Councilmembers, Councilmember candidates, affiliated political committees, and constituent-service programs. Contractors must provide detailed information for each contribution, including the date, amount, and recipient, and must disclose whether the business entity held any District contracts at the time of the contribution or within one year prior. The certification also requires disclosure of any prior or current violations of D.C. Official Code § 1-1163.34a and requires the contractor to certify compliance with the Campaign Finance Reform Amendment Act of 2018.
The form requires the contractor to provide the business name, Tax ID, mailing address, and the names and titles of all company principals, defined as senior officers with authority to set or influence overall business strategy. The contractor must designate individuals authorized to modify the certification on behalf of the business and execute the form under oath before a notary public. The contractor certifies that all information is accurate and complete, that records will be kept updated, and that the business entity will not violate the Campaign Finance Reform Amendment Act of 2018. No pricing terms, set-asides, incumbents, or contract award dates are addressed in this certification form.
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Text version
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF GENERAL SERVICES
ttachment P
Campaign Finance Reform Act - ontractor Self-Certification
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):
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).
https://code.dccouncil.gov/us/dc/council/laws/22-250
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):
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).
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 .