financial-disclosures-and-conflicts-of-interest-v.23.1~3.docx

FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS

The Financial Disclosures and Conflicts of Interest form (“form”) must be accurately completed and submitted by the vendor, parent entity(ies), and subcontractors. There are nine steps to this form and each must be completed as instructed. A bid, offer, or response with an annual value of more than $100,000 that does not include this form shall be considered non-responsive. The Agency will consider this form when evaluating the bid, offer, or response or awarding the contract. A vendor seeking or holding a contract with an annual value of more than $100,000 shall provide this form which will become a material part of the contract.

The requirement of disclosure of financial interests and conflicts of interest is a continuing obligation. If circumstances change and the disclosure is no longer accurate, then disclosing entities must provide an updated form.

Separate forms are required for the vendor, parent entity(ies), and subcontractors.

This disclosure is submitted for:

|_| Vendor |_| Vendor’s Parent Entity(ies) (100% ownership) |_| Subcontractor(s) |_| Subcontractor’s Parent Entity(ies) (100% ownership)

EP 1

STATE OF ILLINOIS

FINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST

State of Illinois Chief Procurement Office for General Services 1 Financial Disclosures and Conflicts of Interest V.23.1 State of Illinois Chief Procurement Office General Services 6 Financial Disclosures and Conflicts of Interest V.23.1

STEP 1

SUPPORTING DOCUMENTATION SUBMITTAL

You must select one of the six options below and select the documentation you are submitting. You must provide the documentation that the applicable section requires with this form.

|_| Option 1 – Publicly Traded Entities

1.B. |_| Attach a copy of the Federal 10-K or provide a web address of an electronic copy of the Federal 10-K, and skip to Step 3.

|_| Option 2 – Privately Held Entities with more than 100 Shareholders

|_| Option 3 – All other Privately Held Entities, not including Sole Proprietorships 3.A. |_| Complete Step 2, Option A for each qualifying individual or entity holding any ownership or distributive income share in excess of 5% or an amount greater than 60% ($123,420) of the annual salary of the Governor.

|_| Option 4 – Foreign Entities

4.B. |_| Attach a copy of the Securities Exchange Commission Form 20-F or 40-F and skip to Step 3.

|_| Option 5 – Not-for-Profit Entities |_| Complete Step 2, Option B.

|_| Option 6 – Sole Proprietorships |_| Skip to Step 3.

STEP 2

DISCLOSURE OF FINANCIAL INTEREST OR BOARD OF DIRECTORS

(All entity types, except sole proprietorships must complete)

Complete either Option A (for all entities other than not-for-profits) or Option B (for not-for-profits). Additional rows may be inserted into the tables or an attachment may be provided if needed.

OPTION A – Ownership Share and Distributive Income

Ownership Share – If you selected Option 1.A., 2.A., 2.B., 3.A., or 4.A. in Step 1, provide the name and address of each individual or entity and their percentage of ownership if said percentage exceeds 5%, or the dollar value of their ownership if said dollar value exceeds $123,420.

|_| Check here if including an attachment with requested information in a format substantially similar to the format below.

TABLE – X

Distributive Income – If you selected Option 1.A., 2.A., 3.A., or 4.A. in Step 1, provide the name and address of each individual or entity and their percentage of the disclosing vendor’s total distributive income if said percentage exceeds 5% of the total distributive income of the disclosing entity, or the dollar value of their distributive income if said dollar value exceeds $123,420.

|_| Check here if including an attachment with requested information in a format substantially similar to the format below.

TABLE – Y

FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS

Please certify that the following statements are true.

I have disclosed all individuals or entities that hold an ownership interest of greater than 5% or greater than $123,420.

|_| Yes |_| No

I have disclosed all individuals or entities that were entitled to receive distributive income in an amount greater than $123,420 or greater than 5% of the total distributive income of the disclosing entity.

|_| Yes |_| No OPTION B – Disclosure of Board of Directors (Not-for-Profits) If you selected Option 5 in Step 1, list members of your board of directors. Please include an attachment if necessary.

TABLE – Z

STEP 3

DISCLOSURE OF LOBBYIST OR AGENT

|_| Yes |_| No. Is your company represented by or do you employ a lobbyist required to register under the Lobbyist Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or other agent who is not identified through Step 2, Option A above and who has communicated, is communicating, or may communicate with any State officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name and address below.

If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist’s information.

Describe all costs/fees/compensation/reimbursements related to the assistance provided by each representative lobbyist or other agent to obtain this Agency contract: Click here to enter text.

STEP 4

PROHIBITED CONFLICTS OF INTEREST

Step 4 must be completed for each person disclosed in Step 2, Option A and for sole proprietors identified in Step 1, Option 6 above. Please provide the name of the person for which responses are provided: Click here to enter text.

STEP 5

POTENTIAL CONFLICTS OF INTEREST RELATING TO PERSONAL RELATIONSHIPS

Step 5 must be completed for each person disclosed in Step 2, Option A and for sole proprietors identified in Step 1, Option 6 above.

Please provide the name of the person for which responses are provided: Click here to enter text.

STEP 6

EXPLANATION OF AFFIRMATIVE RESPONSES

If you answered “Yes” in Step 4 or Step 5, please provide on an additional page a detailed explanation that includes, but is not limited to the name, salary, State agency, and position title of each individual.

STEP 7

POTENTIAL CONFLICTS OF INTEREST

RELATING TO DEBARMENT & LEGAL PROCEEDINGS

This step must be completed for each person and entity disclosed in Step 2, Option A, Step 3, and for each entity and sole proprietor disclosed in Step 1.

Please provide the name of the person or entity for which responses are provided: Click here to enter text.

If you answered “Yes”, please provide a detailed explanation that includes, but is not limited to the name, State agency, and position title of each individual. Click here to enter text. STSTEP 8

STEP 8

DISCLOSURE OF CURRENT AND PENDING CONTRACTS

If you selected Option 1, 2, 3, 4, or 6 in Step 1, do you have any contracts, pending contracts, bids, proposals, subcontracts, leases or other ongoing procurement relationships with units of State of Illinois government?

|_| Yes |_| No.

If “Yes”, please specify below. Additional rows may be inserted into the table or an attachment may be provided if needed.

Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Please explain the procurement relationship: Click here to enter text. STEP 9

STEP 9

SIGN THE DISCLOSURE

This disclosure is signed, and made under penalty of perjury for all for-profit entities, by an authorized officer or employee on behalf of the bidder or offeror pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code. This disclosure information is submitted on behalf of:

Name of Disclosing Entity: Click here to enter text.

Signature: Date: Click here to enter text.

Printed Name: Click here to enter text.

Title: Click here to enter text.

Phone Number: Click here to enter text.

Email Address: Click here to enter text.

State of Illinois Chief Procurement Office General Services 7 Financial Disclosures and Conflicts of Interest V.23.1