Procurement Lobbying Forms

Pursuant to State Finance Law §§139-j and 139-k, this project includes and imposes certain restrictions on contact with the New York State Workers’ Compensation Board during the procurement process. The term “Contact” is defined by statute and refers to those oral, written or electronic communications that a reasonable person would infer are attempts to influence the governmental procurement. In addition to obtaining the required identifying information, the Agency must inquire and record whether the person or organization that made the contact was the Offerer or was retained, employed or designated on behalf of the Offerer to appear before or contact the Governmental Entity.

An Offerer/bidder is restricted from making contacts from the earliest notice of intent to solicit offers for this project definition through final award and approval of the contract by the Office of the State Comptroller to other than designated staff unless it is a contact that is included among certain statutory exceptions set forth in State Finance Law §139-j(3)(a) the end of the restricted period. This period is hereby termed the “Restricted Period.”

The New York State Workers’ Compensation Board employees are also required to obtain certain information when contacted during the restricted period and make a determination of the responsibility of the Offerer/bidder pursuant to these two statutes.

Certain findings of non-responsibility can result in rejection for contract award and in the event of two findings within a 4 year period, the Offerer/bidder is debarred from obtaining governmental procurement contracts. Further information about these requirements can be found at https://ogs.ny.gov/acpl.

PROCUREMENT LOBBYING FORMS:

Affirmation of Understanding of and Agreement pursuant to State Finance Law §139-j

(3) and §139-j (6) (b)

Offerer’s Certification of Compliance with State Finance Law §139-k(5)

Offerer Disclosure of Prior Non-Responsibility Determinations https://ogs.ny.gov/acpl

Affirmation of Understanding of and Agreement pursuant to State Finance Law §139-j (3) and §139-j (6) (b)

The New York State Finance Law §139-j(6)(b) provides that:

Every Governmental Entity shall seek written affirmations from all Offerers as to the Offerer’s understanding of and agreement to comply with the Governmental Entity’s procedures relating to permissible contacts during a Governmental Procurement pursuant to subdivision three of this section.

As a “Governmental Entity,” the New York State Workers’ Compensation Board must obtain the required affirmation of understanding and agreement to comply with procedures on procurement lobbying restrictions regarding permissible contacts in the restricted period for a procurement contract in accordance with State Finance Law §§139-j and 139-k.

_____________________ affirms that it understands and agrees to comply with the (Name of Offerer/bidder’s firm) procedures of the New York State Workers’ Compensation Board relative to permissible contacts as required by State Finance Law §139-j (3) and §139-j (6) (b).

By: ___________________________________ Date:____________________ (PRINT Name of Authorized Representative)

Signature:____________________________________

Title: _________________________________

Contractor Address: _____________________________________________________

Offerer’s Certification of Compliance with State Finance Law §139-k(5)

New York State Finance Law §139-k(5) requires that every Procurement Contract award subject to the provisions of State Finance Law §§139-k or 139-j shall contain a certification by the Offerer that all information provided to the New York State Workers’ Compensation Board with respect to State Finance Law §139-k is complete, true and accurate.

The NYS Workers’ Compensation Board must obtain the required certification that the information is complete, true and accurate regarding any prior findings of non-responsibility, such as non-responsibility pursuant to State Finance Law §139-j. The Offerer must agree to the certification and provide it to the procuring Governmental Entity.

Offerer Certification of Compliance with State Finance Law §139-k(5)

II. Offerer Certification:

I certify that all information provided to the New York State Workers' Compensation Board with respect to State Finance Law §139-k is complete, true and accurate.

By: ___________________________________ Date:____________________ (PRINT Name of Authorized Representative)

Signature: ________________________________

Title: _________________________________

Contractor Address:

Offerer Disclosure of Prior Non-Responsibility Determinations

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 Governmental 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 the next questions:

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 Governmental 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 pages as necessary)

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

6. If yes, please provide details below.

Governmental Entity: ______________________________________________

Date of Termination or Withholding of Contract: ______________________________________

Basis of Termination or Withholding: ____________________________________________

(Add additional pages as necessary)

Offerer certifies that all information provided to the Governmental Entity with respect to State Finance Law §139-k is complete, true and accurate.

By (PLEASE PRINT):

Date:

Signature