OCFS-4822 Procurement Lobbying Act Ceritifcation.dot

OCFS-4822 (9/2006)

OCFS-4822 (9/2006)

New York State

Office of Children and Family Services

Procurement Lobbying Act – Offerer Certification Form

· Disclosure of Prior Non-Responsibility Determinations

· Affirmation of Understanding and Agreement

· Certification of Compliance

Name of Individual or Entity Seeking to Enter into the Procurement Contract:

Address:

Contract Procurement Number:

Yes

FORMCHECKBOX

No

If you answered Yes to question number 1, please answer questions 2 and 3. If not, skip to question 4.

2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law

§139-j?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

3. Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Governmental Entity?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

4. Has any Governmental Entity or other Government agency terminated or withheld a

Procurement Contract with the above-named individual or entity due to the intentional provision of false or incomplete information?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

5. If you answered yes to any of the questions above, please provide the following details regarding the finding of non-responsibility, termination, or withholding of a contract.

Government Entity:

Date of Finding of Non-Responsibility, Termination or Withholding of Contract:

Basis of Finding of Non-Responsibility, Termination or Withholding of Contract (Add additional pages if/as necessary):

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

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

By:

(Signature)

PRINT NAME:

PRINT TITLE:

Reviewed 1/2013

OCFS-4822 (9/2006)

Instructions Procurement Lobbying Act Certification Form

Background

Offerer Disclosure of Prior Non-Responsibility Determinations

New York State Finance Law §139-k(2) obligates a Governmental Entity to obtain specific information regarding prior non-responsibility determinations with respect to State Finance Law §139-j. This information must be collected in addition to the information that is separately obtained pursuant to State Finance Law §163(9) which relates to vendor responsibility for a broader range of reasons. In accordance with State Finance Law §139-k, an offerer must be asked to disclose whether there has been a finding of non-responsibility made within the previous four (4) years by any governmental entity due to: (a) a violation of State Finance Law §139-j or (b) the intentional provision of false or incomplete information to a governmental entity. The terms “offerer” and “governmental entity” are defined in State Finance Law § 139-k(1). State Finance Law §139-j sets forth detailed requirements about the restrictions on contacts during the procurement process. A violation of State Finance Law §139-j includes, but is not limited to, an impermissible contact during the restricted period (for example, contacting a person or entity other than the designated contact person, when such contact does not fall within one of the exemptions).

As part of its responsibility determination, State Finance Law §139-k(3) mandates consideration of whether an offerer fails to timely disclose accurate or complete information regarding the above non-responsibility determination. In accordance with law, no procurement contract shall be awarded to any offerer that fails to timely disclose accurate or complete information under this section, unless a finding is made that the award of a procurement contract to the offerer is necessary to protect public property or public health safety, and that the offerer is the only source capable of supplying the required article of procurement within the necessary timeframe. See State Finance Law §§139-j(10)(b) and 139-k(3).

Offerer’s Certification and Affirmation of Understanding of and Agreement pursuant to State Finance Law Section 139-j and k:

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.

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 procuring governmental entity with respect to State Finance Law §139-k is complete, true and accurate.

Reviewed 1/2013