PLL Certification Form (04-24)10.pdf
PDF 174 KB Posted
- Attached to
- RQ24-008 Bridge Maintenance Material Region 9
- Solicitation number
- 2119139
- Issued by
- Broome County, New York
About this file
This is a Procurement Lobbying Act Certification Form from the New York State Department of Transportation (NYSDOT) that must be completed by entities seeking to enter into procurement contracts. The form requires disclosure of prior non-responsibility determinations within the previous four years and affirmation of understanding and agreement to comply with State Finance Law procedures regarding permissible contacts.
The form consists of three main parts: entity identification, disclosure of prior non-responsibility determinations, and affirmation of compliance. It specifically requires disclosure of any violations of State Finance Law §139-j, intentional provision of false or incomplete information, and any contract terminations or withholdings by governmental entities. The form requires detailed information about any prior findings of non-responsibility, including the government entity involved, dates, and basis for such determinations. No specific pricing terms, set-asides, or funding requirements are mentioned in this compliance document.
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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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