Disclosure Statement.pdf
PDF 558 KB Posted
- Attached to
- Lester Patterson Road Site Remediation (UAD)
- Solicitation number
- SRC0000033016
- Issued by
- Wilcox County, Alabama
About this file
This is a Disclosure Statement form required by the State of Alabama under Article 3B of Chapter 16 of Title 41, Code of Alabama 1975, applicable to state and local contract opportunities. The form applies to contracts meeting or exceeding formal solicitation thresholds and grant proposals exceeding $25,000. The document serves as a standardized disclosure mechanism for entities submitting contract proposals, requests for proposals, invitations to bid, or grant proposals to state agencies and departments.
The disclosure form requires completing entities to identify prior work or goods provided to state agencies in the current or preceding fiscal year, including amounts received, and any grants previously awarded by state agencies. Entities must disclose all public officials, public employees, and their family members with whom the entity or its employees have family relationships and who may directly or indirectly benefit financially from the proposed transaction, specifying the relevant state department or agency. Additionally, the form requires detailed descriptions of any direct and indirect financial benefits to such individuals resulting from the contract or grant. The form also requires listing all paid consultants and lobbyists utilized to obtain the contract or grant. Signatories certify under penalty of perjury that all statements are true and correct, with violations subject to civil penalties of $10,000 or 10 percent of the contract amount, whichever is less, and potential contract or grant voidability by the awarding agency.
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Text version
State of Alabama
Disclosure Statement Required by Article 3B of Chapter 16 of Title 41, Code of Alabama 1975
ENTITY COMPLETING FORM
ADDRESS
CITY, STATE, ZIP TELEPHONE NUMBER
STATE AGENCY/DEPARTMENT THAT WILL RECEIVE GOODS, SERVICES, OR IS RESPONSIBLE FOR GRANT AWARD
ADDRESS
CITY, STATE, ZIP TELEPHONE NUMBER
This form is provided with:
Contract Proposal Request for Proposal Invitation to Bid Grant Proposal
Have you or any of your partners, divisions, or any related business units previously performed work or provided goods to any State
Agency/Department in the current or last fiscal year?
Yes No
If yes, identify below the State Agency/Department that received the goods or services, the type(s) of goods or services previously pro-vided, and the amount received for the provision of such goods or services.
Have you or any of your partners, divisions, or any related business units previously applied and received any grants from any State
Agency/Department in the current or last fiscal year?
Yes No
If yes, identify the State Agency/Department that awarded the grant, the date such grant was awarded, and the amount of the grant.
1. List below the name(s) and address(es) of all public officials/public employees with whom you, members of your immediate family, or any of your employees have a family relationship and who may directly personally benefit financially from the proposed transaction.
Identify the State Department/Agency for which the public officials/public employees work. (Attach additional sheets if necessary.)
STATE AGENCY/DEPARTMENT TYPE OF GOODS/SERVICES AMOUNT RECEIVED
STATE AGENCY/DEPARTMENT DATE GRANT AWARDED AMOUNT OF GRANT
NAME OF PUBLIC OFFICIAL/EMPLOYEE ADDRESS STATE DEPARTMENT/AGENCY
2. List below the name(s) and address(es) of all family members of public officials/public employees with whom you, members of your immediate family, or any of your employees have a family relationship and who may directly personally benefit financially from the proposed transaction. Identify the public officials/public employees and State Department/Agency for which the public officials/public employees work. (Attach additional sheets if necessary.)
NAME OF NAME OF PUBLIC OFFICIAL/ STATE DEPARTMENT/
FAMILY MEMBER ADDRESS PUBLIC EMPLOYEE AGENCY WHERE EMPLOYED
If you identified individuals in items one and/or two above, describe in detail below the direct financial benefit to be gained by the public officials, public employees, and/or their family members as the result of the contract, proposal, request for proposal, invitation to bid, or grant proposal. (Attach additional sheets if necessary.)
Describe in detail below any indirect financial benefits to be gained by any public official, public employee, and/or family members of the public official or public employee as the result of the contract, proposal, request for proposal, invitation to bid, or grant proposal. (Attach additional sheets if necessary.)
List below the name(s) and address(es) of all paid consultants and/or lobbyists utilized to obtain the contract, proposal, request for proposal, invitation to bid, or grant proposal:
By signing below, I certify under penalty of perjury (in the jurisdiction in which it is executed) that all statements on or attached to this form are true and correct to the best of my knowledge. I further understand that a person who knowingly violates this article shall be subject to civil penalty in an amount of ten thousand dollars ($10,000), or 10 percent of the amount of the contract, whichever is less, to be deposited in the State General Fund. Also, the contract or grant shall be voidable by the awarding agency.
Authorized Signatory Date Jurisdiction in which this Disclosure Statement is executed
The disclosure statement is required to be completed and filed with grant proposals in excess of $25,000 and contracts that meet or exceed the threshold for bid or other formal solicitations under Article 5 of Chapter 4 of Title 41 or any other law that requires formal solicitation procedures for awarding public contracts.
NAME OF PAID CONSULTANT/LOBBYIST ADDRESS
| ENTITY COMPLETING FORM: |
| ADDRESS: |
| CITY STATE ZIP: |
| TELEPHONE NUMBER: |
| STATE AGENCYDEPARTMENT THAT WILL RECEIVE GOODS SER: |
| ADDRESS-0: |
| TELEPHONE NUMBER-0: |
| Have you or any of your partners divisions or any: Off |
| Have you or any of your partners divisions or any-1: Off |
| Textfield-5: |
| Authorized Signatory: |
| Date: |
| Jurisdiction in which this Disclosure Statement is: |
| Amt Received Line 1: |
| Amt Received Line 2: |
| Types of Goods/Services Line 1: |
| State AgencyDept Line 1: |
| State AgencyDept Line 3: |
| Types of Goods/Services Line 2: |
| Types of Goods/Services Line 3: |
| State AgencyDept Line 4: |
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| Date Grant Awarded Line 1: |
| Date Grant Awarded Line 2: |
| Date Grant Awarded Line 3: |
| Amt of Grant Line 1: |
| Amt of Grant Line 2: |
| Amt of Grant Line 3: |
| Name of Public Official/Employee Line 1: |
| Address Line 1: |
| State DeptAgency Line 1: |
| Name of Family Member Line 1: |
| State DeptAgency Line 4: |
| Name of Public Official/Employee 4: |
| Address Line 4: |
| State DeptAgency Line 5: |
| Name of Public Official/Employee 5: |
| Name of Public Official/Employee 6: |
| Address Line 5: |
| Address Line 6: |
| Name of Family Member Line 2: |
| Name of Family Member Line 3: |
| Textfield-4: |
| CITY STATE ZIP-0: |
| Provided With: Off |
| Name of Public Official/Employee Line 2: |
| Name of Public Official/Employee Line 3: |
| Address Line 2: |
| Address Line 3: |
| State DeptAgency Line 2: |
| State DeptAgency Line 3: |
| State DeptAgency Line 6: |
| Address Line 7: |
| Address Line 8: |
| Address Line 9: |
| Name of Paid Consultant/Lobbyist Line 1: |
| Name of Paid Consultant/Lobbyist Line 2: |
| Name of Paid Consultant/Lobbyist Line 3: |
| State AgencyDept Line 2: |
| Amt Received Line 3: |
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