PLL Certification Form (04-24).pdf
PDF 174 KB Posted
- Solicitation number
- 2137510
- Issued by
- Albany County, Albany City, New York
About this file
This is a Procurement Lobbying Act Certification Form issued by the New York State Department of Transportation (NYSDOT) for use in conjunction with a competitive solicitation for genuine OEM parts and components for Mack Trucks, John Deere Equipment, and hydraulic supplies. The form serves as an offerer disclosure and compliance verification document required from all bidders participating in the procurement process. The form requires bidders to disclose their entity name and address, confirm understanding of permissible contact procedures under State Finance Law 139-j, and attest to compliance with the government entity's lobbying regulations prior to contract execution. No specific response dates, quantities, or contract terms are detailed within this certification form itself, as those details are contained in the associated Invitation for Bid (IFB) document.
The form requests disclosure of any prior non-responsibility determinations issued by government entities within the previous four years, including the basis for such findings and whether they resulted from violations of State Finance Law 139-j or the intentional provision of false or incomplete information. Bidders must also disclose any contract terminations or withholdings by governmental entities due to misrepresentation. Interested entities are directed to contact the NYSDOT Purchasing Office at (518) 457-4401 or via email at Purch-Assist@dot.ny.gov to obtain the complete bid package and request placement on the bidder's list. All inquiries should reference "BA26-013: Genuine OEM Parts for Mack Truck, John Deere Equipment and Hydraulic Parts" in correspondence.
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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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