Exhibit 3 - Vendor Disclosure Statement Form.pdf

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Attached to
NEJC17008 BCEC Weight Room Floor Materials
Solicitation number
DQ1 GJRA 2017000403 1
Issued by
Lincoln County, Colorado

About this file

This is a Vendor Disclosure Statement Form established under Colorado Revised Statute 24-102-206, applicable to all state contracts and solicitations for services executed after August 3, 2007. The form requires vendors to disclose whether any services under the contract or any subcontracts are anticipated to be performed outside the United States or Colorado. If services will be performed outside these jurisdictions, vendors must identify the specific country(ies) and/or state(s) where work will occur and provide a detailed explanation of why it is necessary or advantageous to perform the contract or subcontracts outside the United States or the State of Colorado. The form requires vendors to supply their name and the contract routing number.

The disclosure requirement does not apply to contracts to which the State is a party under Medicare, the Colorado Medical Assistance Act (Articles 4 to 6 of Title 25.5 CRS), the Children's Basic Health Plan Act (Article 8 of Title 25.5 CRS), or the Colorado Indigent Care Program (Part I of Article 4 of Title 25.5 CRS). This form serves as a compliance mechanism to ensure transparency regarding the geographic location of contract performance and to document the justification for any work performed outside Colorado or the United States.

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Text version

January 24, 2008

VENDOR DISCLOSURE STATEMENT

Contract Performance Outside the United States or Colorado

Colorado Revised Statute 24-102-206

To the extent the vendor has not disclosed the following information in the Statement of Work, this form shall be completed and returned to the contracting agency. This applies to all state contracts and solicitation for services executed after August 3, 2007.

1. Are any services under the contract or any subcontracts anticipated to be performed outside the United States or Colorado?

Yes No

If “Yes”, please complete the following three questions:

2. Where will the services be performed under the contract, including any subcontracts?

(List country(ies) and/or state(s).

3. Explain why it is necessary or advantageous to go outside of the United States or the

State of Colorado to perform the contract or any subcontracts.

4. Contract Routing Number:

Vendor Name:

Not required for contracts to which the State is a party under:

• Medicare

• The “Colorado Medical Assistance Act”, Articles 4 to 6 of Title 25.5 CRS

• The “Children/s Basic Health Plan Act”, Article 8 of Title 25.5, CRS

• The “Colorado Indigent Care Program”, Part I of Article 4 of Title 25.5, CRS

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