PLL Certification Form (04-24).pdf
PDF 174 KB Posted
- Attached to
- Region 8 Traffic Signs
- Solicitation number
- 2138969
- Issued by
- New York
About this file
This is a Procurement Lobbying Act Certification Form issued by the New York State Department of Transportation for use in state procurement contracts. The form serves as an offerer disclosure document requiring prospective contractors to certify their understanding of and compliance with permissible contact procedures under State Finance Law 139-j. The form requires disclosure of any prior non-responsibility determinations made against the individual or entity within the previous four years, including whether such determinations resulted from violations of State Finance Law 139-j or the intentional provision of false or incomplete information to a government entity. Additionally, the form requires disclosure of any termination or withholding of procurement contracts by governmental entities due to the intentional provision of false or incomplete information.
The certification form functions as a compliance and affirmation document whereby the offerer acknowledges understanding and agrees to comply with the procedures established by the government entity regarding permissible contacts as required by State Finance Law 139-j(3) and 139-j(6)(b). The form requires the authorized representative to sign and date the certification, providing the business entity name, address, and the signatory's printed name and title. This document applies to the Region 8 Traffic Signs procurement for the New York State Department of Transportation, which establishes a one-time purchase contract for traffic signs and related materials serving six counties: Columbia, Dutchess, Putnam, Orange East, Orange West, and Ulster. The procurement includes contracting goals for Service-Disabled Veteran-Owned Businesses at 6.00 percent, Minority Business Enterprises at 1.00 percent, and Women Business Enterprises at 8.00 percent.
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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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