PLL Certification Form (04-24).pdf
PDF 174 KB Posted
- Attached to
- RQ26-002 AGGREGATES FOR MAINTENANCE USE ON VENDOR PLACED PAVING PROJECTS – CLINTON COUNTY
- Solicitation number
- 2138314
- Issued by
- Chenango County, New York
About this file
This is a Procurement Lobbying Act Certification Form from the New York State Department of Transportation required for vendors seeking to enter into procurement contracts with the state. The form serves as an official disclosure document and compliance agreement for contractors participating in state procurement opportunities. Part 1 of the form requires vendors to provide their entity name and address. Part 2 requests disclosure of any prior non-responsibility determinations made by governmental entities within the previous four years, including whether such determinations were based on violations of State Finance Law 139-j or the intentional provision of false or incomplete information. Part 2 also requires disclosure of any contract terminations or withholdings by governmental entities due to intentional provision of false or incomplete information. Part 3 requires the offerer to affirm understanding of and agreement to comply with the procedures established by the governmental entity regarding permissible contacts as required under State Finance Law 139-j(3) and 139-j(6)(b).
The certification form must be signed and dated by an authorized representative of the vendor and includes fields for the signatory's printed name and title. This form is applicable to Request for Quotations RQ26-002 for aggregates for maintenance use on vendor-placed paving projects in Clinton County, New York. All vendors submitting quotations must complete and submit this certification as part of their bid package. Communications regarding this procurement must be directed exclusively to the designated contact persons: Jessica Owen at (518) 457-0775 or Jessica.Owen@dot.ny.gov, or Melanie Martin at (518) 457-3508 or Melanie.Martin@dot.ny.gov. Any impermissible contacts initiated by or on behalf of a vendor through other channels may result in disqualification.
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Text version
NEW YORK STATE DEPARTMENT OF TRANSPORTATION
PROCUREMENT LOBBYING ACT CERTIFICATION FORM
Offerer Disclosure of Prior Non-Responsibility Determina�ons and Understanding and Agreement to Comply
PART 1 - NAME AND ADDRESS OF INDIVIDUAL OR ENTITY SEEKING TO ENTER INTO THE PROCUREMENT CONTRACT
ENTITY NAME: ________________________________________
ADDRESS: ________________________________________
Part 2 – DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS
2. Has any government En�ty made a finding of non-responsibility regarding the individual or en�ty seeking to enter into the Procurement Contract in the previous four years?
If YES, please also answer ques�ons 2-4. If NO, skip to ques�on 6. Yes No
3. Was the basis for the finding of non-responsibility due to a viola�on of State Finance Law §139-j? Yes No
4. Was the basis for the finding of non-responsibility due to the inten�onal provision of false or incomplete informa�on to a Government En�ty? Yes No
5. If you answered YES to any of the above ques�ons, please provide details regarding the funding of non-responsibility below:
Government En�ty:
Date of Finding of Non-Responsibility:
Basis of Finding of Non-Responsibility:
(attach additional pages as necessary to provide sufficient detail)
6. Has any Governmental En�ty or other Governmental agency terminated or withheld a
Procurement Contract with the individual or en�ty seeking to enter into the Procurement Contract due to the inten�onal provision of false or incomplete informa�on? Yes No
7. If you answered YES to any of the above ques�ons, please provide details regarding the funding of non-responsibility below:
Government En�ty:
Date of Termina�on or Withholding of Contract::
Basis of Termina�on or Withholding:
(attach additional pages as necessary to provide sufficient detail)
Part 3 – AFFIRMATION of UNDERSTANDING and AGREEMENT TO COMPLY Offerer affirms this _____ day of _________________, 20__ that it understands and agrees to comply with the procedures of the Government En�ty rela�ve to permissible contacts as required by State Finance Law §139-j(3) and §139-j(6)9b).
Business En�ty Name and Address:
By (signature) ______________________________________________ Date: ___________________ Print Name and Title: _________________________________________________________________
Contract/Procurement #
| ContractProcurement: |
| Yes: Off |
| No: Off |
| Yes_2: Off |
| No_2: Off |
| Yes_3: Off |
| No_3: Off |
| Yes_4: Off |
| No_4: Off |
| day of: |
| Print Name and Title: |
| Date: |
| Text1: |
| Text2: |
| Text3: |
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