PLL Certification Form (04-24)21.pdf
PDF 174 KB Posted
- Attached to
- RQ26-004 AGGREGATES FOR MAINTENANCE USE ON VENDOR PLACED PAVING PROJECTS – ST. LAWRENCE COUNTY
- Solicitation number
- 2139954
- Issued by
- St. Lawrence 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 by vendors seeking to enter into procurement contracts with the agency. The form serves as an offerer disclosure document requiring vendors to certify their understanding of and compliance with New York State Finance Law Section 139-j regarding permissible contacts during the procurement process. The form applies to the RQ26-004 solicitation for Aggregates for Maintenance Use on Vendor Placed Paving Projects in St. Lawrence County, New York. Vendors must complete the certification form by the submission deadline to be considered for award.
The certification form requires vendors to disclose any prior non-responsibility determinations made by governmental entities within the previous four years, including findings based on violations of State Finance Law 139-j or the intentional provision of false or incomplete information. Vendors must also disclose any instances where governmental entities terminated or withheld procurement contracts due to the intentional provision of false or incomplete information. By signing the affirmation section, vendors acknowledge their understanding of and agreement to comply with the government entity's procedures regarding permissible contacts as required by State Finance Law 139-j(3) and 139-j(6)(b). All communications regarding this procurement must be directed to the designated contact persons: Jennifer Walter at (518) 457-9434 or Jennifer.Walter@dot.ny.gov, or Relina Sosa at (518) 485-5192 or Relina.Sosa@dot.ny.gov.
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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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