Campaign_Finance_Reform_Contractor_Self-Certification_Form.pdf
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- Solicitation number
- DCAM-26-AE-RFP-0002
- Issued by
- District of Columbia
About this file
This is a Contractor Self-Certification Form issued by the District of Columbia in compliance with D.C. Law 22-250, the Campaign Finance Reform Amendment Act of 2018, applicable to the Architectural/Engineering Services Request for Proposals for the FEMS-Engine House 15 Facility Modernization project. The form requires all contractors bidding on District contracts to disclose any political contributions made since November 9, 2022, to the Mayor, Attorney General, or any Councilmember, as well as any associated candidates or affiliated political committees and constituent-service programs. Contractors must provide detailed information about each contribution including the date, amount, and recipient, and must identify whether the business entity held any District contracts at the time of the contribution or within one year prior.
The certification form requires contractors to declare whether they have been determined to be in violation of D.C. Official Code § 1-1163.34a, whether they are currently in violation, and to certify that they will not be in violation going forward. Contractors must identify all principals of the business entity, including senior officers such as owners, presidents, chief executive officers, and similar positions that influence overall business strategy, and must designate individuals authorized to modify the certification. The form must be completed, sworn before a notary public, and certified as accurate and complete, with signatures required from an authorized representative of the contracting business entity.
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Text version
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
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