NFP-Procurements-Required-Forms.pdf

Required Administrative Forms for Not-for-Profit Procurements

May 2026

Administrative Forms Checklist

To Be Provided with Applicant’s Proposal:

Gender-Based Violence and the Workplace – State Finance Law §139-M

Prohibiting State Agencies and Authorities from Contracting with Businesses Conducting Business in Russia – EO 16

MacBride Fair Employment Principles – State Finance Law §165

Prohibiting Contracts with Entities that Support Discrimination – EO 177

Sexual Harassment Prevention – State Finance Law §139-I

Non-Collusive Bidding – State Finance Law §139-D

Offeror Disclosure of Prior Non-Responsibility Determinations

Affirmation of Understanding and Agreement Pursuant to State Finance Law §139-j & k

Contractor’s Certification/Acknowledgement/Understanding

Offeror Assurance of No Conflict of Interest or Detrimental Effect (Offeror, Subcontractors, Consultants)

OTDA-4970 - MWBE and EEO Policy Statement

Applicant Certification

Vendor Responsibility Questionnaire

Contact Information Form

To Be Completed Upon Award:

OTDA-4934 - EEO Staffing Plan

Confidentiality/Non-Disclosure Agreement - This form must be completed by all employees, volunteers, or contractors working for the applicant or for an entity that the applicant subcontracts with.

The completed forms must be submitted to OTDA upon request.

Gender-Based Violence and the Workplace Ce rtification New York State Finance Law §139-M requires bidders on competitive state procurements to certify that they have a written policy addressing gender-based violence and the workplace and that such policy meets the following minimum requirements:

● Share Information: Employers must provide information regarding gender-based violence where employees can see and access it, including displaying the NYS Domestic and Sexual Violence Hotline information and a gender-based violence and the workplace poster.

● Refer Employee-Survivors to Services: The policy must require that the employer refer employees who disclose current or past victim status to the NYS Domestic and Sexual Violence Hotline and/or a local service provider. For bidders outside of New York State, referrals should be made to a local provider or statewide hotline. While referrals are required to be provided by the employer, it is not required for the employee to access services.

● Prohibit Retaliation: The policy must clearly state that discrimination or retaliation against employees who identify as victims or survivors of gender-based violence is prohibited.

● Comply with Laws: Ensure your policy follows State law. For employers based in New York State, this means that the policy must follow the SAFE Leave Act, New York State Human Rights Law, and any other relevant laws and regulations.

● Offer Implementation Support: OPDV is able to assist employers in developing and implementing this policy. Employers must provide information to supervisors and human resources, where available, about this technical assistance from OPDV.

OPDV can be contacted at workplace@opdv.ny.gov.

By submission of this bid, each bidder and each person signing on behalf of any bidder certifies, and in the case of a joint bid each party thereto certifies its own organization, under penalty of perjury, that they have and have implemented a written policy addressing gender-based violence and the workplace and has provided such policy to all of its employees, directors and board members. Such policy shall, at minimum, meet the requirements of subdivision 11 of section five hundred seventy-five of the executive law.

Organization’s signature below certifies its compliance with State Finance Law §139-M.

Organization: __________________________________________________________

By (signature): _________________________________________________________ Name (Please Print): ____________________________________________________ Title: _________________________________________________________________ Date: ________________________________________________________________ This form must be signed by an authorized executive or legal representative.

If the organization cannot make the above certification, they must provide an attached statement with their bid detailing the reasons therefor.

mailto:workplace@opdv.ny.gov mailto:workplace@opdv.ny.gov

Certifcation Under Executive Order No. 16 Prohibiting State Agencies and Authorities from Contracting with

Businesses Conducting Business in Russia

Executive Order No. 16 provides that “all Afected State Entities are directed to refrain from entering into any new contract or renewing any existing contract with an entity conducting business operations in Russia.” The complete text of Executive Order No. 16 can be found here.

The Executive Order remains in efect while sanctions imposed by the federal government are in efect.

Accordingly, vendors who may be excluded from award because of current business operations in Russia are nevertheless encouraged to respond to solicitations to preserve their contracting opportunities in case the sanctions are lifted during a solicitation or even after award in the case of some solicitations.

As defned in Executive Order No. 16, an “entity conducting business operations in Russia” means an institution or company, wherever located, conducting any commercial activity in Russia or transacting business with the Russian Government or with commercial entities headquartered in Russia or with their principal place of business in Russia in the form of contracting, sales, purchasing, investment, or any business partnership.

Is Vendor an entity conducting business operations in Russia, as defned above? Please answer by checking one of the following boxes:

1. No, Vendor does not conduct business operations in Russia within the meaning of Executive Order No. 16.

2.a. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but has taken steps to wind down business operations in Russia or is in the process of winding down business operations in Russia. (Please provide a detailed description of the wind down process and a schedule for completion.)

2.b. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but only to the extent necessary to provide vital health and safety services within Russia or to comply with federal law, regulations, executive orders, or directives. (Please provide a detailed description of the services being provided or the relevant laws, regulations, etc.)

3. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16.

The undersigned certifes under penalties of perjury that they are knowledgeable about the Vendor’s business and operations and that the answer provided herein is true to the best of their knowledge and belief.

Vendor Name:

(legal entity)

By:

(signature)

Name:

Title:

Date:

https://www.governor.ny.gov/executive-order/no-16-prohibiting-state-agencies-and-authorities-contracting-businesses-conducting

Nondiscrimination in Employment in Northern Ireland:

MacBride Fair Employment Principles

In accordance with Section 165 of the State Finance Law, the Bidder, by submission of this bid certifies that it, or any individual or legal entity in which the Bidder holds a 10% or greater ownership interest, or any individual or legal entity that holds a 10% or greater ownership in the Bidder, either: (answer yes or no to one or both of the following, as applicable),

1. Has business operations in Northern Ireland:

Yes ___ or No ___

If yes:

2. Shall take lawful steps in good faith to conduct any business operations that it has in Northern Ireland in accordance with the MacBride Fair Employment Principles relating to nondiscrimination in employment and freedom of workplace opportunity regarding such operations in Northern Ireland and shall permit independent monitoring of their compliance with such Principles.

Yes ___ or No ___

Signature: _____________________________________________________________

Prohibiting Contracts with Entities That Support Discrimination EO 177 Certification

The New York State Human Rights Law, Article 15 of the Executive Law, prohibits discrimination and harassment based on age, race, creed, color, national origin, sex, pregnancy or pregnancy-related conditions, sexual orientation, gender identity, disability, marital status, familial status, domestic violence victim status, prior arrest or conviction record, military status, or predisposing genetic characteristics.

The Human Rights Law may also require reasonable accommodation for persons with disabilities and pregnancy-related conditions. A reasonable accommodation is an adjustment to a job or work environment that enables a person with a disability to perform the essential functions of a job in a reasonable manner. The Human Rights Law may also require reasonable accommodation in employment on the basis of Sabbath observance or religious practices.

Generally, the Human Rights Law applies to:

• all employers of four or more people, employment agencies, labor organizations and apprenticeship training programs in all instances of discrimination or harassment;

• employers with fewer than four employees in all cases involving sexual harassment;

and,

• any employer of domestic workers in cases involving sexual harassment or harassment based on gender, race, religion, or national origin.

In accordance with Executive Order No. 177, the Bidder hereby certifies that it does not have institutional policies or practices that fail to address the harassment and discrimination of individuals on the basis of their age, race, creed, color, national origin, sex, sexual orientation, gender identity, disability, marital status, military status, or other protected status under the Human Rights Law.

Executive Order No. 177 and this certification do not affect institutional policies or practices that are protected by existing law, including but not limited to the First Amendment of the United States Constitution, Article 1, Section 3 of the New York State Constitution, and Section 296 (11) of the New York State Human Rights Law.

Contractor: ______________________________________________________

By: ______________________________________________________

Name: ______________________________________________________

Title: ______________________________________________________

Date: ______________________________________________________

Sexual Harassment Prevention Certification

State Finance Law §139-I requires bidders on state procurements to certify that they have a written policy addressing sexual harassment prevention in the workplace and provide annual sexual harassment training (that meets the Department of Labor’s model policy and training standards) to all its employees.

“By submission of this bid, each bidder and each person signing on behalf of any bidder certifies, and in the case of a joint bid each party thereto certifies its own organization, under penalty of perjury, that the bidder has and has implemented a written policy addressing sexual harassment prevention in the workplace and provides annual sexual harassment prevention training to all of its employees. Such policy shall, at a minimum, meet the requirements of section two hundred one-g of the labor law.”

Contractor: __________________________________________________________

Printed Name: _________________________________________________________

Title: __________________________________________________________

Signature: __________________________________________________________

Date: __________________________________________________________

Bids that do not contain the certification will not be considered for award; provided however, that if the bidder cannot make the certification, the bidder may provide a signed statement with their bid detailing the reasons why the certification cannot be made.

Non-Collusive Bidding Certification Required by Section 139-D of State Finance Law

Section 139-D. Statement of Non-Collusion in Bids to the State:

By submission of this bid, Bidder and each person signing on behalf of Bidder certifies, and in the case of joint bid, each party thereto certifies as to its own organization, under penalty of perjury, that to the best of his/her knowledge and belief:

1. The prices of this bid have been arrived at independently, without collusion, consultation, communication, or agreement, for the purposes of restricting competition, as to any matter relating to such prices with any other Bidder or with any competitor.

2. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the Bidder and will not knowingly be disclosed by the Bidder prior to opening, directly or indirectly, to any other Bidder or to any competitor.

3. No attempt has been made or will be made by the Bidder to induce any other person, partnership, or corporation to submit or not to submit a bid for the purpose of restricting competition.

A bid shall not be considered for award nor shall any award be made where 1, 2, and 3 above have not been complied with; provided however, that if in any case the Bidder(s) cannot make the foregoing certification, the Bidder shall so state and shall furnish below a signed statement which sets forth in detail the reasons therefore:

[Affix addendum to this page if space is required for statement.]

Subscribed to under penalty of perjury under the laws of the State of New York, this

____ day of ___________________, 20___ as the act and deed of said corporation or partnership.

Exhibit 1: Non-Collusive Bidding Certification-3

Identifying Data

Potential Contractor: _____________________________________________________

Street Address: _________________________________________________________

City, State, Zip: _________________________________________________________

Telephone: ____________________________________________________________

Title: _________________________________________________________________

If applicable, Responsible Corporate Officer:

Name: ________________________________________________________________

Title: _________________________________________________________________

Signature: _____________________________________________________________

Joint or combined bids by companies or firms must be certified on behalf of each participant.

Legal Name (Person/Firm/Corporation)

By:

Name

Title

Street Address

City State Zip

Legal Name (Person/Firm/Corporation)

Name

Title

Street Address

City State Zip

Offeror Disclosure of Prior Non-Responsibility Determinations (Procurement Lobbying Act)

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?

No Yes

If yes, please answer the next questions.

2. Was the basis for the finding of non-responsibility due to violation of State Finance Law §139-j?

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?

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 provision of false or incomplete information?

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)

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

Signature: ____________________________________________________________

Date: ______________________________________________________________

Name: _______________________________________________________________

Title: ________________________________________________________________

Procurement Lobbying Act Offeror’s Certification and Affirmation of Understanding of and Agreement pursuant to State Finance Law §139-j and k

Offeror affirms that it understands and agrees to comply with the New York State procedures relative to permissible contacts as required by State Finance Law §139-j.

(https://www.nysenate.gov/legislation/laws/STF/139-J)

By: ___________________________________________________________________

Date: _________________________________________________________________

Name: ________________________________________________________________

Title: _________________________________________________________________

Contractor Name: _______________________________________________________

Contractor Address: _____________________________________________________

Offeror Certification:

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

(https://www.nysenate.gov/legislation/laws/STF/139-K)

Authorized Signature: ____________________________________________________ https://www.nysenate.gov/legislation/laws/STF/139-J https://www.nysenate.gov/legislation/laws/STF/139-K

Contractor’s Certification/Acknowledgements/Understanding

Contractor’s Acknowledgement of Understanding of Post- Employment Provisions

The Authorized Signatory of the Contractor acknowledges that he/she has the authority to sign on behalf of the Contractor, has read and understands the provisions applicable to post-employment restrictions affecting former State officers and employees, and agrees to abide by the Provisions of the Public Officer’s Law during the term of the Agreement.

Contractor’s Disclosure of Any Existing and/or Contemplated Conflict of Interest

Have you any existing or contemplated relationship with any other person or entity, including relationships with any member, shareholders of 5% or more, parent, subsidiary, of affiliated firm, which would constitute an actual or potential conflict of interest or appearance of impropriety, relating to other clients/customers of the Contractor or former officers and employees of the Agencies and their Affiliates, in connection with your rendering services enumerated in this Agreement?

Yes ___ No ___

If your answer to the above is “Yes”, please attach a written explanation, include a statement with your Agreement documents describing how your Staffing Firm would eliminate or prevent the Conflict of Interest. Indicate what procedures will be followed to detect, notify OTDA of, and resolve any such conflicts.

By my signature on this form, I certify that all information disclosed to the State is complete, true, and accurate with regard to Conflicts of Interest.

Contractor’s Disclosure of Former State Employees

Do you employ and/or use any subcontractors who are former employees of OTDA that will be assigned to perform services under this Agreement?

Yes ___ No ___

If your answer to the above is “Yes”, please attach a written statement identifying any/all employees and/or subcontractors who are former employees of OTDA that will be assigned to perform services under this Agreement, include a description of their work duties, and the dates of their employment.

By my signature on this form, I certify that all information disclosed to the State is complete, true, and accurate with regard to Former State Employees.

Contractor’s Disclosure of Any Investigation or Disciplinary Action by the New York State Commission on Public Integrity or its Predecessor State Entities (Collectively, “Commission”)

Have you or any of your members, shareholders of 5% or more, parents, affiliates, or subsidiaries, been the subject of any investigation or disciplinary action by the New York State Commission on Public Integrity or its predecessor State entities (collectively, “Commission”)?

Yes ___ No ___

If your answer to the above is “Yes”, please attach a written explanation;

include a statement with your Proposal providing a brief description indicating how any matter before the Commission was resolved, or whether it remains unresolved.

By my signature on this form, I certify that all information disclosed to the State is complete, true, and accurate with regard to investigations or disciplinary actions by the Commission.

Contractor’s Agreement to Notify OTDA of Potential Future Conflicts

By signature below, the Authorized Signatory of the Contractor, certifies that he/she will notify OTDA of any/all new potential conflicts of interest and any/all new contractor staff that are prior OTDA employees during the term of the contract, prior to hiring of said individual, and will complete and submit an updated version of this form to OTDA at the time of becoming aware of any such new potential conflicts of interest, and of any/all new contractor or subcontractor staff that are prior OTDA employees.

The Signature Below Indicates Certification/Acknowledgement/Understanding of Each of the Above

Authorized Signatory: ___________________________________________________

Date: ________________________________________________________________

Printed Name: _________________________________________________________

Title: _________________________________________________________________

Contract Number: _______________________________________________________

Offeror Assurance of No Conflict of Interest or Detrimental Effect

The Offeror proposing to provide services pursuant to this solicitation, as Contractor, Joint venture contractor, subcontractor, or consultant, attests that its performance of the services outlined in this solicitation does not and will not create a conflict of interest with nor, position the Offeror to breach any other Agreement currently in force with the State of New York.

Furthermore, the attests that it will not act in any manner that is detrimental to any State project on which the Offeror is rendering services. Specifically, the Offeror attests that:

1. The fulfillment of obligations by the Offeror, as proposed in the response, does not Violate any existing Contracts or Agreements between the Offeror and the State.

2. The fulfillment of obligations by the Offeror, as proposed in the response, does not and will not create any conflict of interest, or perception thereof, with any current role or responsibility that the Offeror has with regard to any existing Contracts or Agreements between the Offeror and the State.

3. The fulfillment of obligations by the Offeror, as proposed in the response, does not and will not compromise the Offeror’s ability to carry out its obligations under any existing Agreements between the Offeror and the State.

4. The fulfillment of any other contractual obligations that the Offeror has with the State will not affect or influence its ability to perform under any Agreement with OTDA resulting from this RFP.

5. During the negotiation and execution of any Agreement resulting from this RFP, the Offeror will not knowingly take any action or make any decision which creates a Potential for conflict of interest or might cause a detrimental impact to the State as a whole including, but not limited to, any action or decision to divert resources from one State project to another.

6. In fulfilling obligations under each of its State contracts, including any Agreement which results from this RFP, the Offeror will act in accordance with the terms of each of its State contracts and will not knowingly take any action or make any decision which might cause a detrimental impact to the State as a whole including, but not limited to, any action or decision to divert resources from one State project to another.

7. No former officer or employee of the State who is now employed by the Offeror, nor any former officer or employee of the Offeror who is now employed by the State, has played a role with regard to the administration of this procurement in a manner that may violate section 73(8)(a) of the State Ethics Law.

8. The Offeror has not and shall not offer to any employee, member, or director of OTDA any gift, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any ither form, under circumstances in which it could reasonably be inferred that the gift was intended to influence said employee, member, or director, or could reasonably be expected to influence said employee, member, or director in the performance of the official duty of said employee, member, or director or was intended as a reward for any official action on the part of said employee member, or director.

Offerors responding to this RFP should note that OTDA recognizes that conflicts may occur in the future because an Offeror may have existing or new relationships. OTDA will review the nature of any such new relationship and reserves the right to terminate the Agreement for cause if, in its judgment, a real or potential conflict of interest cannot be cured.

Signature: _____________________________________________________________

Date: _________________________________________________________________

Name: _____________________________________________________________

Title: _______________________________________________________________

Note: This form must be signed by an authorized executive or legal representative (person that is authorized to bind the Offeror contractually).

Revised 03/2026 OTDA-4970 1

KATHY HOCHUL

Governor

BARBARA C. GUINN

Commissioner

RAJNI CHAWLA

Executive Deputy Commissioner

MINORITY AND WOMEN-OWNED BUSINESS ENTERPRISES -

EQUAL EMPLOYMENT OPPORTUNITY POLICY STATEMENT

I, , (the awardee/contractor) agree to adopt the following policies with respect to the project being developed or services rendered at

M/WBE

This organization will and will cause its contractors and subcontractors to take good faith actions to achieve the M/WBE contract participations goals set by the State for that area in which the State-funded project is located, by taking the following steps:

1. Actively and affirmatively solicit bids for contracts and subcontracts from qualified State certified MBEs or WBEs, including solicitations to M/WBE contractor associations.

2. Request a list of State-certified M/WBEs from AGENCY and solicit bids from them directly.

3. Ensure that plans, specifications, request for proposals and other documents used to secure bids will be made available in sufficient time for review by prospective M/WBEs.

4. Where feasible, divide the work into smaller portions to enhanced participations by M/WBEs and encourage the formation of joint venture and other partnerships among M/WBE contractors to enhance their participation.

5. Document and maintain records of bid solicitation, including those to M/WBEs and the results thereof.

The Contractor will also maintain records of actions that its subcontractors have taken toward meeting M/WBE contract participation goals.

6. Ensure that progress payments to M/WBEs are made on a timely basis so that undue financial hardship is avoided, and that, if legally permissible, bonding and other credit requirements are waived or appropriate alternatives developed to encourage M/WBE participation.

EEO

1. This organization will not discriminate against any employee or applicant for employment because of race, creed, color, national origin, sex, age, disability or marital status, will undertake or continue existing programs of affirmative action to ensure that minority group members are afforded equal employment opportunities without discrimination, and shall make and document its conscientious and active efforts to employ and utilize minority group members and women in its work force on state contracts.

2. This organization shall state in all solicitation or advertisements for employees that in the performance of the State contract all qualified applicants will be afforded equal employment opportunities without discrimination because of race, creed, color, national origin, sex disability or marital status.

3. At the request of the contracting agency, this organization shall request each employment agency, labor union, or authorized representative will not discriminate on the basis of race, creed, color, national origin, sex, age, disability or marital status and that such union or representative will affirmatively cooperate in the implementation of this organization’s obligations herein.

4. The Contractor shall comply with the provisions of the Human Rights Law, all other State and Federal statutory and constitutional non-discrimination provisions. The Contractor and subcontractors shall not discriminate against any employee or applicant for employment because of race, creed (religion), color, sex, national origin, sexual orientation, military status, age, disability, predisposing genetic characteristic, marital status or domestic violence victim status, and shall also follow the requirements of the Human Rights Law with regard to non- discrimination on the basis of prior criminal conviction and prior arrest.

5. This organization will include the provisions of sections (a) through (d) of this agreement in every subcontract in such a manner that the requirements of the subdivisions will be binding upon each subcontractor as to work in connection with the State contract.

Agreed to this day of , 20

By

Print: Title:

Revised 03/2026 OTDA-4970 2

(Name of Designated Liaison) is designated as the Minority Business Enterprise Liaison responsible for administering the Minority and Women- Owned Business Enterprises- Equal Employment Opportunity (M/WBE-EEO) program.

M/WBE Contract Goals

Minority and Women’s Business Enterprise Participation

Minority Business Enterprise Participation

Women’s Business Enterprise Participation

Authorized Representative Date

Title

APPLICANT CERTIFICATION

The applicant certifies that to the best of their knowledge and belief the information in this application is true and correct, and that if funded, they will ensure compliance with program requirements, as outlined in this RFP.

Organization: __________________________________________________________

By (signature): _________________________________________________________

Name (Please Print): ____________________________________________________

Title: _________________________________________________________________

Date: ________________________________________________________________

New York State Vendor Responsibility Questionnaire

The Office of Temporary and Disability Assistance recommends that vendors file the required Vendor Responsibility Questionnaire online via the New York State VendRep System; however, vendors may choose to complete and submit a paper questionnaire.

To enroll in and use the New York State VendRep System, see the VendRep System Instructions available at http://www.osc.ny.gov/vendrep/vendor_index.htm or go directly to the VendRep System Online at https://onlineservices.osc.state.ny.us.

Please check one of the following:

A Vendor Responsibility Questionnaire has been filed online and has been certified/updated within the last six months.

A Vendor Responsibility Questionnaire is attached to this Bid/Proposal.

http://www.osc.ny.gov/vendrep/vendor_index.htm https://onlineservices.osc.state.ny.us/

40 North Pearl Street, Albany, NY 12243-0001 | otda.ny.gov

Governor

BARBARA C. GUINN

Commissioner

RAJNI CHAWLA

Executive Deputy Commissioner

Contractor Contact Information Form

Please complete this form to identify the appropriate contacts for this contract and to ensure award letters and related communications are sent to the correct recipients. Should any individual need to be added to or removed from the list, please inform OTDA immediately.

Agency Name:

Program Name:

Agency Contact – Overall contact for official correspondence and award letters

Name:

Title:

Email Address:

Phone Number:

Mailing Address – Line 1:

Mailing Address – Line 2:

City, State, ZIP:

Program Contact – Contract-specific for day-to-day questions, site visit coordination and contract administration

Name:

Title:

Email Address:

Phone Number:

Mailing Address – Line 1:

Mailing Address – Line 2:

City, State, ZIP:

40 North Pearl Street, Albany, NY 12243-0001 | otda.ny.gov

Authorized Signatory / Signatories – For Claims for Payment submitted under this contract

Authorized Signatory #1 – Name:

Authorized Signatory #1 – Title:

Authorized Signatory #2 – Name:

Authorized Signatory #2 – Title:

Authorized Signatory #3 – Name:

Authorized Signatory #3 – Title:

Revised 03/2026 OTDA-4934 1

Governor

BARBARA C. GUINN

Commissioner

RAJNI CHAWLA

Executive Deputy Commissioner

[OTDA-4934] STAFFING PLAN

Submit with Bid or Proposal – Instructions on page 3

Solicitation No.: Reporting Entity:

Offeror’s Name:

Offeror’s Address:

Report includes Contractor’s/Subcontractor’s:

Work force to be utilized on this contract Total work force

Offeror Subcontractor

Subcontractor’s name

Workforce by Gender

EEO-Job Category Total

Workforce Male Female X

Officials/Administrators

Professionals

Technicians

Sales Workers

Office/Clerical

Craft Workers

Laborers

Service Workers

Temporary /Apprentices

Totals

Revised 03/2026 OTDA-4934 2

Workforce by Race/Ethnicity Identification

EEO-Job Category Total Workforce

White

(M) (F) (X)

Black

(M) (F) (X)

Asian

(M) (F) (X)

Native American

(M) (F) (X)

Disabled

(M) (F) (X)

Veteran

(M) (F) (X)

Officials/Administrators

Professionals

Technicians

Sales Workers

Office/Clerical

Craft Workers

Laborers

Service Workers

Temporary/Apprentices

Totals

PREPARED BY (Signature): TELEPHONE NO.:

EMAIL ADDRESS:

DATE:

NAME AND TITLE OF PREPARER (Print or Type): Submit completed with bid or proposal MWBE 101 (Rev 03/11)

Revised 03/2026 OTDA-4934 3

General Instructions All Offerors and each subcontractor identified in the bid or proposal must complete an EEO Staffing Plan (MWBE 101) and submit it as part of the bid or proposal package. Where the work force to be utilized in the performance of the State contract can be separated out from the contractor’s and/or subcontractor’s total work force, the Offeror shall complete this form only for the anticipated work force to be utilized on the State contract. Where the work force to be utilized in the performance of the State contract cannot be separated out from the contractor’s and/or subcontractor’s total work force, the Offeror shall complete this form for the contractor’s and/or subcontractor’s total work force.

Instructions for Completing

1. Enter the Solicitation number that this report applies to along with the name and address of the Offeror.

2. Check off the appropriate box to indicate if the Offeror completing the report is the contractor or a subcontractor.

3. Check off the appropriate box to indicate work force to be utilized on the contract or the Offerors’ total work force.

4. Enter the total work force by EEO job category.

5. Break down the anticipated total work force by gender and enter under the heading ‘Work force by Gender’

6. Break down the anticipated total work force by race/ethnic identification and enter under the heading ‘Work force by Race/Ethnic Identification’.

Contact the OMWBE Permissible contact(s) for the solicitation if you have any questions.

7. Enter information on disabled or veterans included in the anticipated work force under the appropriate headings.

8. Enter the name, title, phone number and email address for the person completing the form. Sign and date the form in the designated boxes.

Race/Ethnicity Identification Race/ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. For the purposes of this form, an employee may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be counted in more than one race/ethnic group. The race/ethnic categories for this survey are:

WHITE

BLACK

HISPANIC

ASIAN & PACIFIC ISLANDER

NATIVE INDIAN (NATIVE

AMERICAN/ALASKAN NATIVE)

OTHER CATEGORIES

DISABLED INDIVIDUAL

VIETNAM ERA VETERAN

GENDER

(Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East a person, not of Hispanic origin, who has origins in any of the black racial groups of the original peoples of Africa.

a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

a person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or the Pacific Islands.

a person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.

any person who: has a physical or mental impairment that substantially limits one or more major life activity(ies); has a record of such an impairment; or is regarded as having such an impairment.

a veteran who served at any time between and including January 1, 1963 and May 7, 1975.

Male, Female, or Non-binary

Confidentiality/Non-Disclosure Agreement

With regard to my work with ______________________(Requestor)

I, (Individual’s name) am:__________________________ an employee of Requestor a volunteer with Requestor a contractor of Requestor an employee of a contractor of Requestor a volunteer with a contractor of Requestor a subcontractor to a contractor of Requestor an employee of a subcontractor to Requestor a volunteer with a subcontractor to Requestor and;

A. Access or Exposure Protected Information In General

I understand that as part of performing my duties as an employee, volunteer, contractor or subcontractor I may have access to, see or hear “Protected Information,” which, for purposes of this agreement, shall include, but not be limited to:

1. Data or information obtained from sources outside of OTDA, such as Federal Tax Information (FTI); Federal Parent Locator Services (FPLS) information;

Unemployment Insurance Benefit (UIB) information; Social Security Administration (SSA) information; and, Medicaid (MA) information.

2. Data or information maintained in and/or obtained from OTDA-owned applications, systems, networks and/or databases, including but not limited to:

Welfare Management System (WMS); Child Support Management System (CSMS); Automated State Support Enforcement and Tracking System (ASSETS); Benefits Issuance Control System (BICS); Cognos; Workforce Archive Retrieval Manager (WARM) report system; and/or the Commissioner’s Dashboard.

3. Data or information identifying an individual, particularly where such disclosure could result in an unwarranted invasion of personal privacy. Such data or information may include, but is not limited to: home addresses; telephone numbers; Social Security numbers; client identification numbers; payroll information; financial information; health information; and/or, eligibility and benefit information;

4. Computer codes or other electronic or non-electronic data or information, the disclosure of which could jeopardize the compliance stature, security or confidentiality of OTDA’s information technology solutions, applications, systems, networks or data;

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5. Non-final OTDA policy or deliberative data or information related to the official business of OTDA;

6. Data or information which is not otherwise required to be disclosed under the NYS Freedom of Information Law;

7. Any other material designated by OTDA as being “Confidential,” “Personal,” “Private” or otherwise “Sensitive.”

I acknowledge and agree that all Protected Information (oral, visual or written, including both paper and electronic) which I see or to which I have access shall be treated as strictly confidential and shall not be released, copied or otherwise re-disclosed, in whole or in part, unless expressly authorized by the New York State Office of Temporary and Disability Assistance (OTDA).

I understand and agree that access to and the use of Protected Information obtained in the performance of my duties shall be limited to purposes directly connected with such duties, unless otherwise provided in writing by OTDA. When access to such information or data also results in access to Protected Information or data beyond that which is necessary for the purpose for which access was granted, I agree to access only that Protected Information needed for the purpose for which access was given.

When I no longer require the use of or access to such Protected Information, whether because of termination of employment, reassignment of job duties or otherwise, I agree that I will not access or attempt to access any Protected Information, including, but not limited to any Protected Information in State systems or other sources, to which I have been given access. I will return any and all reports, notes, memoranda, notebooks, drawings, data and other Protected Information developed, received, compiled by or delivered to me in order to carry out my functions or which may be in my possession, regardless of the source of the Protected Information. Any Protected Information not returned will be catalogued, and thereafter securely scrubbed, shredded, or otherwise disposed of in accordance with New York State Policies.

I understand that federal and State law and regulation prohibit the release or disclosure of such Protected Information, in whole or part. I acknowledge and hereby agree that I will not copy, re-disclose or otherwise share Protected Information in whole or in part in any form to anyone unless I am expressly directed to do so by my supervisor and such disclosure complies with applicable federal and State law and regulation. I further understand that if I am unsure as to what information is confidential, I will immediately, and prior to any such access, use, or re-disclosure, consult with OTDA or my supervisor.

I will safeguard, and will not disclose to unauthorized parties, any user name and/or password that may be issued to me in furtherance of my access to the Protected Information unless authorized. I understand that my access to Protected Information may be revoked at any time if my responsibilities change, or for any other reason at the discretion and direction of OTDA, or my supervisor. Further, I will not facilitate access or disclosure of Protected Information to any unauthorized person or entity, whether by knowingly providing my user name and/or password or otherwise.

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I will comply with all applicable Federal and State confidentiality, record security, compliance and retention laws, regulations, policies and procedures including, but not limited to, those set out in Attachment A.

I will immediately report to my supervisor any activities by any individual or entity that I have reason to believe may compromise the availability, integrity, security or privacy of the Protected Information. I will immediately notify OTDA and my supervisor of any request for Protected Information that does not come from an individual directly involved in the project.

I agree not to attach or load any hardware or software to or into any State or Requestor equipment unless properly authorized, in writing, to do so by OTDA. I will use only my access rights to, and will access only those systems, directories, and Protected Information authorized for my use by OTDA.

I will not use OTDA telecommunications, Internet, E-mail or other services or equipment for any illegal, disruptive, unethical or unprofessional activities, for personal gain, or for any purpose that could jeopardize the legitimate interests of the State or expose some or all Protected Information.

I agree not to knowingly take any actions that may intrude upon, disrupt or deny OTDA or Requestor services or the flow of any Protected Information.

I agree to store any Protected Information received in secure, locked containers or, where stored on a computer or other electronic media, in accordance with state and federal law and regulation, as well as OTDA’s and New York State Office of Information Technology Services’ (ITS) security policies that protects Protected Information from unauthorized disclosure.

I agree that no brochure, news/media/press release, public announcement, memorandum or other information of any kind regarding this Agreement or any Protected Information shall be disseminated in any way to the public, nor shall any presentation be given regarding this Agreement without the prior written approval of

OTDA.

B. Access or Exposure to Information With Heightened Obligations:

I. Child Support Information

1. I acknowledge that, through attendance at a training program provided or approved by OTDA, I have been advised of the laws, regulations, policies, and rules governing use and disclosure of child support information, including federal information (as defined below) and agree to follow the same.

2. I will not access child support information on any system maintained by New York State for any purpose other than those permitted by law, including:

• Actions necessary to establish paternity, establish, modify or enforce orders of child support or combined orders of child and spousal support.

• The administration of the child support program, including data and systems management.

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• Verifying child support or combined child and spousal support payments to persons in Medicaid (MA), Temporary Aid to Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) households as part of an eligibility determination or recertification;

• Obtaining information about child support orders and combined orders of child and spousal support for the purpose of administering the MA, TANF or SNAP program.

• Investigation of fraud in the MA, TANF, or SNAP program.

3. I will not access any cases, accounts, files or screens except those necessary to perform my duties

4. I understand that all child support information I have access to, whether in paper, electronic, or other format is confidential and may not be used or disclosed for any other purpose, or be released to any party, without prior written consent of the OTDA Division of Child Support Enforcement or (if employed by a social services district) the Coordinator of the child support unit of the social services district where I am employed, or the designee of either.

5. I understand that any access, use, or disclosure for any unauthorized purpose without prior written consent as set forth in paragraph 4 shall constitute a breach of confidentiality and may result in disciplinary proceeding, criminal charges, and/or civil liability.

NOTICE: Pursuant to Social Services Law 111-v, any person who willfully discloses or permits disclosure or release of Confidential Information obtained hereunder shall be guilty of a class A misdemeanor and shall be liable to any person who incurs damages due to said disclosure in a civil action.

II. Federal Information

1. For the purposes of this Agreement, “federal information” shall mean all information obtained through the Federal Parent Locator System (FPLS), including National Directory of New Hires (NDNH), and the Federal Case Registry (FCR). The FPLS is an automated national information system which locates employment, income, asset and home address information on parents in child support cases. The NDNH contains new hire (W-4), quarterly wage (QW) and unemployment insurance (UI) information on employees in both the public and private sector. The FCR collects and maintains records provided by state child support agency registries, which include abstracts of support orders and information from child support cases. This information must be safeguarded as required by state and federal rules whether in transmission or at rest, and in both electronic and paper form. Federal information must be protected from improper disclosure in accordance with state and federal rules regardless of where it is stored or displayed, including the Automated State Support Enforcement and Tracking System (ASSETS), the Child Support Management System (CSMS), and Workforce Archive Retrieval Manager (WARM), or a local system. Federal information that has been independently verified is no longer federal information, but remains child support information subject to Section I, above.

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2. I will not access federal information for any purpose other than those permitted by law, including:

• Actions necessary to establish paternity, establish, modify or enforce order of child support or combined orders of child and spousal support.

• The administration of the child support program.

• Information obtained from the NDNH or FCR may be disclosed to agencies administering plans or programs under titles IV-A, IV-B, IV-D and IV-E of the federal Social Security Act for the purpose of assisting that program to carry out its responsibilities of administering title IV-A, IV-B, IV-D and IV-E programs.

• Certain location and employment information from the FPLS may be disclosed to locate an individual for the purposes of establishing parentage or relative foster care under titles IV-B or IV-E of the federal social security act.

• I acknowledge that paragraphs three through five in Section B, I above, apply to use, disclosure and safeguarding of federal information.

III. Federal Tax Return Information

I have read the quoted provisions of Section 6103, 7213, 7213A and 7431 of the Internal Revenue Code contained in Attachment B of this Agreement and I understand that Section 6103 of the Internal Revenue Code imposes strict confidentiality requirements on child support enforcement personnel who have or have had access to federal tax returns or…