NO_CONFLICTS_FORM_10-2018.pdf

Revised 10/2018

2018 1

NO CONFLICTS / DISCLOSURE FORM

EVERY BUSINESS OR INDIVIDUAL THAT IS ISSUED A NOTICE OF

INTENT TO AWARD PURSUANT TO THE CITY’S PURCHASING

ORDINANCE (Section 3.08.070, AS AMENDED), MUST FULLY

AND ACCURATELY COMPLETE THIS DISCLOSURE FORM. IF

THERE IS INSUFFICIENT SPACE FOR ANY ANSWER, ATTACH

ADDITIONAL SHEETS.

Name of Individual or Business: _______________________________

Person signing this form: _____________________________________ Title:_______________________________

Phone Number: ( ) ______-_______

The undersigned hereby represents and warrants that the following statements are true, correct and complete, to the best of his/her knowledge and belief, and that the City of Bridgeport is entitled to rely thereon:

1. Business is (check one)

� a corporation � a general partnership � a limited liability company � a sole proprietorship � a limited liability partnership � other _____________.

2. Business Address: __________________________________________________

3. State of incorporation or organization: � Connecticut

� Other ______________

4. What other trade names does the Business use, if any?

5. Fed. ID or SS #______________ CT State ID # ______________

DUNS # ______________ SAM # ______________

CT Contractors # ____________ Other pertinent license #s (if any)

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6. (a) Identify all officers, directors, managing or general partners, or managing members.

Name Address Title

(b) Identify owners of 5% or more interest in the Business:

7. Identify any parent, affiliate or subsidiary organization of the Business.

(a) Company’s name ___________________________________, a

� a corporation � a general partnership � a limited liability company � a sole proprietorship � a limited liability partnership � other _____________

State of Incorporation or organization: ______________

Relationship to your company:_____________________

(b) Company’s name ___________________________________, a

� a corporation � a general partnership � a limited liability company � a sole proprietorship � a limited liability partnership � other _____________

State of Incorporation or organization: ______________ Relationship to your company:____________________

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8. Has the Business, any parent, affiliate or subsidiary company, or any of their respective officers, directors, owners, general partners, managing members, within the past three (3) years been convicted of, entered a plea of guilty, entered a plea of nolo contendere, concluded or served a sentence imposed for, or otherwise admitted to:

Yes No

a) the commission of a criminal offense as an incident to obtaining or attempting to obtain a public or private contract or subcontract, � � or in the performance of such contract or subcontract?

b) the violation of any state or federal law for embezzlement, theft, forgery, bribery, falsification or destruction of records, receiving stolen property � � or any other offense indicating a lack of business integrity or business honesty which affects responsibility as a municipal contractor?

c) the violation of any state or federal antitrust, collusion or conspiracy law arising out of the submission of bids or proposals to a public or � � private contract or subcontract?

d) fraudulent, criminal or other seriously improper conduct while � � participating in a joint venture or similar arrangement.

e) willfully failing to perform in accordance with the terms of one or � � more public contracts, agreements or transactions?

f) having a history of failure to perform or a history of unsatisfactory performance of one or more public contracts, agreements or � � transactions?

g) willfully violating a statutory or regulatory provision or requirement applicable to a public contract, agreement or transaction? � �

IF YOU ANSWER YES TO ANY PART OF PARAGRAPH 7, EXPLAIN

ON AN ATTACHED SHEET.

9. Initial as appropriate below:

None of the persons listed herein is related by blood or marriage to any City of Bridgeport government official or employee. ________ (Initial)

OR

One or more of the persons listed herein is related by blood or marriage to a City of Bridgeport government official or employee. (Explain in detail below or attach additional sheet if necessary). ________ (Initial)

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10. Does the Business, any parent, affiliate or subsidiary company, or any of their respective officers, directors, owners, general partners, managing members, employees, or agents have any business or familial relationship, through ownership, directorship, contractual arrangement, control, or other arrangement with any of the subcontractors to be used on the work involved in the bid for which this form is being submitted?

IF YOU ANSWER YES TO ANY PART OF PARAGRAPH 9, EXPLAIN

ON AN ATTACHED SHEET.

11. Read and initial at the end of the following paragraph:

BY INITIALING BELOW, THE UNDERSIGNED REPRESENTS THAT

THERE EXISTS NO KNOWN OR SUSPECTED CONFLICTS OF INTEREST

BETWEEN THE BUSINESS, ITS PARENT, AFFILIATES OR SUBSIDIARIES

AND THE CITY OF BRIDGEPORT. ________ (Initial)

12. Read and initial at the end of the following paragraph:

BY INITIALING BELOW, THE UNDERSIGNED UNDERSTANDS THAT THE

DUTY TO PROVIDE THE INFORMATION REQUESTED IN THIS FORM IS A

CONTINUING OBLIGATION AND THAT THE INFORMATION REQUIRED

BY THIS FORM MUST AND WILL BE PROMPTLY UPDATED UPON ANY

CHANGE. ________ (Initial)

WARNING: Falsifying information on this form, or failing to promptly notify the City of changes to the information contained in it during the course of the Business’ performance of the work will constitute a default under any contract or purchase order awarded to the Business, and will permit the City to terminate its contract with the Business and pursue its legal rights and remedies as to such Business or persons associated therewith.

Dated:________________________ _________________________ Name:

Title:

duly-authorized

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STATE OF ___________}

}ss. ________ ________ ___, 20__

COUNTY OF _________}

Personally appeared before me, ______________________(name), the __________________________(title) of __________________________(name of Business), who swore to the truth of the foregoing as his/her free act and deed and the free act and deed of _______________________(name of Business) before me.

Notary Public:

My commission expires on:

Commissioner of the Superior Court