NYS-Required-Forms-2025.pdf

Page 1 of 10 NYS Required Forms (Revised 10/23/2025)

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

By submission of this response, the Offerer and each person signing on behalf of Offerer 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 response 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 Offerer or with any competitor;

[2] Unless otherwise required by law, the prices which have been quoted in this response have not been knowingly disclosed by the Offerer and will not knowingly be disclosed by the Offerer prior to opening, directly or indirectly, to any other Offerer or to any competitor; and

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

A RESPONSE 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 OFFERER(S) CANNOT MAKE THE FOREGOING CERTIFICATION, THE OFFERER 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 the act and deed of said corporation or partnership.

IF OFFERER(S) IS (ARE) A PARTNERSHIP, COMPLETE THE FOLLOWING:

NAMES OF PARTNERS/PRINCIPALS LEGAL RESIDENCE

IF OFFERER(S) IS (ARE) A CORPORATION, COMPLETE THE FOLLOWING:

NAME LEGAL RESIDENCE

President:

Secretary:

Treasurer:

NYS Required Certifications

Page 2 of 10 NYS Required Forms

Identifying Data

Offerer

Street Address

City, State and Zip Code

Telephone Title

Fax

If applicable, Responsible Corporate Officer

Name Title

Signature Date

Joint or combined responses by multiple Offerers must be certified on behalf of each participant. Legal name of person, firm or corporation

By Name Title

Street Address

City, State, Zip Code

NYS Required Certifications

NYS Required Forms Page 3 of 10

NYS Required Certification(s) Offerer’s Certification of Adherence to Executive Order 177 regarding

Anti-Discriminatory Policies and Practices

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 Offerer 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.

Offerer Certification:

Date:

I certify adherence to Executive Order No. 177.

Signature:

Printed Name:

Title:

Offerer Name:

Offerer Address:

Procurement Lobbying Restrictions

NYS Required Forms Page 4 of 10

Pursuant to State Finance Law §§139-j and 139-k, certain restrictions are placed on contact with state agencies 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 state 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.

The “Restricted Period” is the period of time commencing with the earliest date of written notice, advertisement or solicitation of a request for proposal, invitation for bids, or solicitation of proposals, or any other method for soliciting a response from Offerers intending to result in a Procurement Contract with a State agency and, ending with the final contract award and approval by, where applicable, the Office of the State Comptroller.

New York State employees are also required to obtain certain information when contacted during the restricted period and make a determination of the responsibility of the Offerer 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 is debarred from obtaining governmental procurement contracts. Further information about these requirements can be found at: https://ogs.ny.gov/acpl.

Any Offerer responding to the solicitation must complete the form found below and submit it to the State agency.

Procurement Lobbying Restrictions

Pursuant to State Finance Law §§139-j and 139-k, certain restrictions are placed on contact with state agencies 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 state 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.

The “Restricted Period” is the period of time commencing with the earliest date of written notice, advertisement or solicitation of a request for proposal, invitation for bids, or solicitation of proposals, or any other method for soliciting a response from Offerers intending to result in a Procurement Contract with a State agency and, ending with the final contract award and approval by, where applicable, the Office of the State Comptroller.

New York State employees are also required to obtain certain information when contacted during the restricted period and make a determination of the responsibility of the Offerer 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 is debarred from obtaining governmental procurement contracts. Further information about these requirements can be found at: https://ogs.ny.gov/acpl.

Any Offerer responding to the solicitation must complete the form found below and submit it to the State agency.

Procurement Lobbying Restrictions

Pursuant to State Finance Law §§139-j and 139-k, certain restrictions are placed on contact with state agencies 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 state 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.

The “Restricted Period” is the period of time commencing with the earliest date of written notice, advertisement or solicitation of a request for proposal, invitation for bids, or solicitation of proposals, or any other method for soliciting a response from Offerers intending to result in a Procurement Contract with a State agency and, ending with the final contract award and approval by, where applicable, the Office of the State Comptroller.

New York State employees are also required to obtain certain information when contacted during the restricted period and make a determination of the responsibility of the Offerer 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 is debarred from obtaining governmental procurement contracts. Further information about these requirements can be found at: https://ogs.ny.gov/acpl.

Any Offerer responding to the solicitation must complete the form found below and submit it to the State agency.

NYS Required Forms Page 5 of 10

Offerer’s Certification of Adherence to New York State Finance Law

1. Offerer certifies that it understands and agrees to comply with the procedures of the NYS and or the contracting agency relative to permissible contacts as required by State Finance Law Section 139-j(3) and Section 139-j(6)(b).

2. CONTRACTOR DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS Pursuant to Procurement Lobbying Law (SFL §139-j)

(a) 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?

Yes No

If yes, please answer the following question:

(b) Was the basis for the finding of non-responsibility due to a violation of State Finance Law §139-j?

Yes No If “Yes” was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a governmental entity?

Yes No If “Yes”, please provide details regarding the finding of non-responsibility:

Governmental Entity:

Date of finding of non-responsibility:

Basis of finding of non-responsibility (attach additional sheets as necessary):

3. Has any governmental entity terminated or withheld a procurement contract with the above-named individual or entity due to the intentional provision of false or incomplete information?

Yes No

If yes, provide details:

Governmental Entity:

Date of Termination or Withholding of Contract:

Basis of Termination or Withholding: (add additional pages if necessary)

4. Offerer certifies that all information provided to NYS or the contracting agency, with respect to State Finance Law Section 139-k is complete, true and accurate.

Name of Offerer(s):

Offerer’s Business Address:

Offerer’s signature: Date:

I understand that my signature represents that I am signing and responding to all certifications listed above.

Print Name:

Title of Person signing this form:

Sexual Harassment Prevention Certification Form

NYS Required Forms Page 6 of 10

State Finance Law Section 139-L

By submission of this bid, each Offerer and each person signing on behalf of any Offerer certifies, and in the case of a joint bid each party thereto certifies as to its own organization, under penalty of perjury, that the Offerer 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 (201g) of the labor law.

Company Name:

Signature:

Print Name and Title:

Date:

If the above certification cannot be made, the Offerer must submit a signed statement below and/or attached detailing the reasons why the certification cannot be made.

Company Name:

Signature:

Print Name and Title:

Date:

Freedom Of Information Law Redaction Request

NYS Required Forms Page 7 of 10

Freedom of Information Law

New York State's Freedom of Information Law (FOIL) (Public Officers Law, Article 6, Sections 84-90), available at:

https://www.dos.ny.gov/coog/foil2.html, promotes the public’s right to know the process of governmental decision-making and grants maximum public access to governmental records. Pursuant to Section 87(2)(d) of FOIL, a State agency may deny access to those portions of proposals or portions of a successful Offerer’s contract which are "trade secrets" or submitted to an agency by a commercial enterprise or derived from information obtained from a commercial enterprise and which, if disclosed, would cause substantial injury to the competitive position of the subject enterprise.

It is an Offerer‘s responsibility to consult an attorney with any questions the Offerer may have about New York State's Freedom of Information Law. All work products described herein may also be subject to FOIL disclosure.

The Offerer must provide to New York State or the contracting agency all information, records, and other written material it produces, possesses, or relies upon if such material is the object of a legitimate request to the New York State or the contracting agency pursuant to the Freedom of Information Law.

The Offerer should indicate below if there is specific information in an Offerer’s proposal that an Offerer claims to be proprietary and/or trade secret information that meets the definition set forth in Section 87(2)(d), the Offerer should provide a letter in its Administrative Proposal outlining any specific concerns regarding disclosure under the New York State Freedom of Information Law (Article 6 of the Public Officers Law).

Confidential, trade secret or proprietary materials as defined by the laws of the State of New York must be clearly marked and identified as such upon submission by the Offerer. The State will not honor any attempt by an Offerer either to designate its entire bid proposal as proprietary and/or to claim copyright protection for its entire proposal.

Please note that all information that an Offerer may claim as proprietary, copyrighted or rights-reserved is not necessarily protected from disclosure under FOIL.

New York State’s or a contracting agency’s receipt/acceptance of the claimed materials does not constitute a determination on the exemption request, which determination will be made in accordance with statutory procedures.

Failure to identify the information which an Offerer believes should be protected by Section 87(2)(d) may result in such information being disclosed if a request is received.

Is the Offerer submitting a Freedom of Information Law Redaction request? If Yes, Offerer should include the specific details of its request as part of the Offerer’s Administrative Proposal.

Yes No

Offerer’s Name:

Name, Title:

Signature: Date:

NYS Required Forms Page 8 of 10

Offerer’s Certification of Adherence to Executive Order No. 16 Prohibiting State Agencies and Authorities from Contracting with Businesses Conducting Business in Russia

Executive Order No. 16 provides that “all Affected 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 effect while sanctions imposed by the federal government are in effect.

Accordingly, Offerers 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 defined 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 Offerer an entity conducting business operations in Russia, as defined above?

Please answer by checking one of the following boxes:

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

2.a.

2.b.

3.

Yes, Offerer 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.)

Yes, Offerer 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.)

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

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

Offerer’s Name:

(legal entity)

Signature:

Name:

Title:

Page 9 of 10 NYS Required Forms

Offerer Assurance of No Conflict of Interest or Detrimental Effect The Offerer proposing to provide services pursuant to this solicitation, as a 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 Offerer to breach any other contract currently in force with the State of New York. Furthermore, the Offerer attests that it will not act in any manner that is detrimental to any State project on which the Offerer is rendering services.

Specifically, the Offerer attests that:

1. The fulfillment of obligations by the Offerer, as proposed in the response, does not violate any existing contracts or agreements between the Offerer and the State;

2. The fulfillment of obligations by the Offerer, 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 Offerer has regarding any existing contracts or agreements between the Offerer and the State;

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

4. The fulfillment of any other contractual obligations that the Offerer has with the State will not affect or influence its ability to perform under any contract with the State resulting from this Solicitation;

5. During the negotiation and execution of any contract resulting from this Solicitation, the Offerer 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 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 contract which results from this Solicitation, the Offerer 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 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 Offerer, nor any former officer or employee of the Offerer who is now employed by the State, has played a role with regard to the administration of this contract procurement in a manner that may violate section 73(8)(a) of the Public Officers Law; and

8. The Offerer has not and shall not offer to any employee, member or director of the State any gift, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any other 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.

Offerer(s) responding to this Solicitation should note that the State recognizes that conflicts may occur in the future because an Offerer may have existing or new relationships. The State will review the nature of any such new relationship and reserves the right to terminate the contract for cause if, in its judgment, a real or potential conflict of interest cannot be cured.

Offerer Name:

By, Name (please print):

Signature:

Title:

This form must be signed by an authorized executive or legal representative.

Gender-Based Violence and the Workplace Certification 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 as to its own organization, under penalty of perjury, that the bidder has and has 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 a 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.

Page 10 of 10 NYS Required Forms mailto:workplace@opdv.ny.gov