Exhibit A - Form of Offerer Disclosure.docx
DOCX document 36 KB Posted
- Solicitation number
- 8152
- Issued by
- Suffolk County, New York
About this file
The document is an Exhibit A Form of Offerer Disclosure related to the Suffolk County Water Authority's procurement process for a contract to furnish and deliver Personal Protective Equipment (PPE), Consumables, and Vending Supplies. The bid is scheduled to be received electronically via BidNetDirect.com/new-york by 11:00 AM on November 12, 2025, with bid documents available on SCWA.com and BidNetDirect.com/new-york. The procurement is open to all bidders, with specific encouragement for Disadvantaged Business Enterprises to participate.
The disclosure form requires bidders to disclose prior non-responsibility determinations, contract terminations, prevailing wage compliance, and potential debarment within the past four to five years. Bidders must provide comprehensive, truthful information about their company's history of governmental contract performance, including any findings of non-compliance, false information provision, or contract terminations. The form is part of the Suffolk County Water Authority's procurement transparency and vendor vetting process for Contract No. 8152, issued on October 21, 2025, and signed by Jeffrey W. Szabo, Chief Executive Officer.
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Other files
| File | Type | Posted |
|---|---|---|
| EXHIBIT C - Insurance Carriers or Agents Acknowledgment Form.docx | DOCX document | |
| EXHIBIT A1 - SCWA Disclosure Form.docx | DOCX document | |
| EXHIBIT B - Affirmation of Understanding and Compliance.docx | DOCX document | |
| Subcontractor Insurance Agreement (If Applicable).docx | DOCX document | |
| Invitation to Bid.pdf | ||
| Non-Collusive Certificate .docx | DOCX document | |
| EXHIBIT D - Contact Info.docx | DOCX document | |
| EXHIBIT E - Contract Prequalification Statement.docx | DOCX document |
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Text version
EXHIBIT A
FORM OF OFFERER DISCLOSURE OF
PRIOR NON-RESPONSIBILITY DETERMINATION
Contract No. _______
Name of Individual or Entity Seeking to Enter into the Procurement Contract:
Address:
Name and Title of Person Submitting this Form:
Contract Procurement Number:
Date:
1. Has any Government Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years?
(Please circle): No Yes
If yes, please answer questions 2 thru 4.
2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law 139-j?
(Please circle): No Yes
3. Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Government Entity?
(Please circle): No Yes
4. If you answered yes to any of the above questions, please provide details regarding the finding of non-responsibility below.
Governmental Entity:
Date of Finding of Non-Responsibility:
Basis of Finding of Non-Responsibility:
(Add additional information on reverse if necessary) All question must be answered.
| 5. | Has any Governmental Entity or other governmental agency terminated or withheld a Procurement Contract with the above-named individual or entity due to the intentional provision of false or incomplete information? | |
| (Please circle): | No | Yes |
If yes, please provide details below:
Governmental Entity:
Date of Termination or Withholding of Contract:
Basis of Termination or Withholding:
(Add additional information on reverse as necessary)
6. Has any agency, including, but not limited to, the New York State Department of Labor, found you to be in violation of, or are you currently under investigation for, failure or the alleged failure to comply with the laws, rules or regulations requiring you to pay prevailing wage and supplements for any public work you or your firm has performed, for the failure or the alleged failure to comply with the laws, rules or regulations concerning the employment of children, or the failure or alleged failure to pay wages, or unemployment insurance tax payments within the past five years?
(Please Circle) No Yes
7. Has any agency, such as a local or state government entity or the federal government debarred your firm?
(Please Circle) No Yes
If yes, please provide details concerning the disbarment.
Offerer certifies that all information provided to the Suffolk County Water Authority with respect to State Finance Law 139-k is complete, true, and accurate.
By: Date:
Signature:
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