ContractorMandatorySubmissionForm.pdf

Updated 11/1/05

CONSULTANT CONTRACTOR MANDATORY SUBMISSION FORM

COMPLETE THE FOLLOWING ONLY FOR CONSULTANT CONTRACTS

(Within HH and NN and UU Object Classes)

Bidder: ________________________________________________________________________ RFR Name/Title: ________________________________________________________________ RFR Number: # _________________________________________________________________

Additional Income Disclosure. Pursuant to the provisions of M.G.L. c. 29, s. 29A, the following amounts represent any contracts, grants or other income due from the Commonwealth of Massachusetts, including any political subdivision or public authority, during the period of a contract. You may attach additional sheets as necessary.

Please check if N/A.

Disclosure of Persons with Financial Interest (other than the bidder). Pursuant to the provisions of M.G.L. c.

29, s 29A and c. 7A, s. 6, the following individuals have a financial interest in a contract and/or with more than one percent (1%) interest in the capital stock of the contractor. You may attach additional sheets as necessary.

Key Personnel. Attach a resume or statement of qualifications for all key personnel specifically named in bidder's response to be assigned to the performance of a contract.

The information submitted herein is certified by the bidder to be accurate under the pains and penalties of perjury.

Signature of Authorized Signatory for Bidder: __________________________________________________

Title of Authorized Signatory for Bidder: _____________________________________________________

Date: __________________________________________________________

Consultant Contractor Mandatory Submission Form