PLL Certification Form (04-24)12.pdf

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 #