PLL Certification Form (04-24).pdf
PDF 174 KB Posted
- Attached to
- Portable Screener & RC Tracked Skid Steer
- Solicitation number
- 2136583
- Issued by
- Richmond County, 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 connection with a solicitation for one Portable Screener and one RC Tracked Skid Steer to be utilized by NYSDOT Region 6. The form requires offerers to disclose their entity name and address, and mandates disclosure of any prior non-responsibility determinations made by government entities within the previous four years, including those based on violations of State Finance Law 139-j or the intentional provision of false or incomplete information. Offerers must also disclose any instances where a governmental entity has terminated or withheld a procurement contract due to intentional provision of false or incomplete information. The form concludes with an affirmation section in which the offerer certifies its understanding of and agreement to comply with the procedures of the government entity relative to permissible contacts as required by State Finance Law 139-j.
The certification form serves as a compliance mechanism to ensure that only responsible bidders participate in NYSDOT procurements and that all offerers acknowledge the restrictions on procurement lobbying activities. Completion and submission of this form is a standard requirement for participation in the competitive bidding process and must be executed by an authorized representative of the business entity seeking to enter into the contract. The form does not address pricing, set-asides, or funding sources; these matters are addressed in the associated Invitation for Bids document referenced in the solicitation announcement.
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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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