EXHIBIT A1 - SCWA Disclosure Form.docx
DOCX document 40 KB Posted
- Solicitation number
- 8152
- Issued by
- Suffolk County, New York
About this file
This document is an Exhibit A1 Disclosure Form for the Suffolk County Water Authority (SCWA), designed to gather vendor information for a procurement opportunity. The form is part of a solicitation for PPE, Consumables, and Vending Supplies, with bids to be submitted electronically via BidNetDirect.com/new-york by 11:00 AM on November 12, 2025. The invitation to bid (ITB) documents are available on SCWA's website and BidNetDirect, with the procurement identified as Contract No. 8152. Disadvantaged Business Enterprises are encouraged to participate in this bidding process.
The disclosure form requires vendors to provide detailed organizational information, including business type, principals, board members, partners, and shareholders with over 5% ownership interest. Vendors must transparently identify any individuals who are also SCWA officers or employees. The form serves as a critical compliance document, with failure to file considered a material breach of contract. Signed under penalty of perjury, the form ensures transparency and accountability in the vendor selection process for this New York state procurement opportunity.
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Other files
| File | Type | Posted |
|---|---|---|
| EXHIBIT C - Insurance Carriers or Agents Acknowledgment 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 A - Form of Offerer Disclosure.docx | DOCX document | |
| EXHIBIT E - Contract Prequalification Statement.docx | DOCX document |
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Text version
EXHIBIT A1
Suffolk County Water Authority Disclosure Form
1. Vendor’s Name ______________________________________________________________ Address_______________________________________________________________________ City and State ________________________________________________ Zip ______________
2. Type of Business: _____Corporation _____Partnership _____Sole Proprietorship _____Other__
3. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Board of Directors or comparable body, names and addresses of all partners, members, and names and addresses of all corporate officers. Conspicuously identify any person in this table of organization who is also an officer or an employee of Suffolk County Water Authority. (Attach additional sheet if necessary.)
4. List all names and addresses of those individual shareholders and members holding more than five percent (5%) interest in the Contractor/vendor. Conspicuously identify any shareholder who is also an officer or an employee of Suffolk County Water Authority. (Attach additional sheet if necessary).
5. Remedies. The failure to file a verified public disclosure statement shall constitute a material breach of Contract.
6. Verification. This section must be signed by an officer or principal of the Vendor authorized to sign for the company for the purpose of executing Contracts. The undersigned being sworn, affirms under the penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to his/her own knowledge, true.
Dated: ______________ Signed: __________________________________________________ Printed Name of Signer: _________________________________________________________ Title of Signer: ________________________________________________________________ Name of Vendor: ______________________________________________________________ image1.jpeg
File details come from the government source that posted it. Updated .