PLL Certification Form _Purchase 11-1212.pdf

Administrative Services Division - Purchasing

NEW YORK STATE DEPARTMENT of TRANSPORTATION

PROCUREMENT LOBBYING ACT — OFFERER CERTIFICATION FORM

PART 1 – DISCLOSURE OF PRIOR NON-RESPONSIBILITY DETERMINATIONS

Name and Address of Individual or Entity Seeking to Enter Into the Procurement Contract

1. Has any Government Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years?

If YES, please also answer questions 2 and 3. If NO, skip to question 4.

Yes

No

2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law § 139-j?

3. Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Government Entity?

3. 4. Has any Governmental Entity or other Governmental agency terminated or withheld a

4. Procurement Contract with the above-named individual or entity due to the intentional

5. provision of false or incomplete information?

6. 5. If you answered YES to any of the questions above, please provide the following details regarding the finding of non-responsibility, termination, or withholding of a contract:

Government Entity:

Date of Finding of Non-Responsibility, Termination, or Withholding of Contract:

Basis of Finding of Non-Responsibility, Termination, or Withholding of Contract:

(Attach additional pages if/as necessary to provide sufficient detail)

PART 2 – CERTIFICATION of COMPLIANCE

Offerer certifies this Day of , 20 that all information provided to the Government Entity with respect to State Finance Law §139-k is complete, true and accurate.

Business Entity Name and Address:

By (Signature) ________________________________________ Print Name and Title

PART 3 – AFFIRMATION of UNDERSTANDING and AGREEMENT

Offerer affirms this Day of , 20 that he/she understands and agrees to comply with the New York State procedures relative to permissible contacts as required by State Finance Law §139-j(3) – (each Offerer that contacts a governmental entity about a governmental procurement shall only make permissible contacts with respect to the governmental procurement during the restricted period) and §139-j(6)(b) – (entity shall seek written affirmations as to the offerer’s understanding and agreement to comply ).

Business Entity Name and Address:

By (Signature) ________________________________________ Print Name and Title

(11/12)

Contract/Procurement

Procurement Lobbying Act

Disclosure, Certification, and Affirmation Form

NYSDOT reserves the right to terminate any contract entered into as a result of this certification if it is found that the certification was intentionally false or intentionally incomplete. Upon such finding, NYSDOT may exercise its termination rights by providing written notification to the Offerer.

Background

Offerer Disclosure of Prior Non-Responsibility Determinations

New York State Finance Law §139-k(2) obligates a Governmental Entity to obtain specific information regarding prior non-responsibility determinations with respect to State Finance Law §139-j. This information must be collected in addition to the information that is separately obtained pursuant to State Finance Law §163(9) which relates to vendor responsibility for a broader range of reasons. In accordance with State Finance Law §139-k, an offerer must be asked to disclose whether there has been a finding of non-responsibility made within the previous four (4) years by any governmental entity due to: (a) a violation of State Finance Law §139-j or (b) the intentional provision of false or incomplete information to a governmental entity. The terms “offerer” and “governmental entity” are defined in State Finance Law § 139-k(1). State Finance Law §139-j sets forth detailed requirements about the restrictions on contacts during the procurement process. A violation of State Finance Law §139-j includes, but is not limited to, an impermissible contact during the restricted period (for example, contacting a person or entity other than the designated contact person, when such contact does not fall within one of the exemptions).

As part of its responsibility determination, State Finance Law §139-k(3) mandates consideration of whether an offerer fails to timely disclose accurate or complete information regarding the above non-responsibility determination. In accordance with law, no procurement contract shall be awarded to any offerer that fails to timely disclose accurate or complete information under this section, unless a finding is made that the award of a procurement contract to the offerer is necessary to protect public property or public health safety, and that the offerer is the only source capable of supplying the required article of procurement within the necessary timeframe.

Offerer’s Certification of Compliance with State Finance Law §139-k(5):

New York State Finance Law §139-k(5) requires that:

Every procurement contract award subject to the provisions of State Finance Law §139-k or §139-j shall contain a certification by the offerer that all information provided to the procuring governmental entity with respect to State Finance Law §139-k is complete, true and accurate.

Offerer’s Affirmation of Understanding and Agreement pursuant to State Finance Law Section 139-j and k:

State Finance Law §139-j(6)(b) further provides that:

Every governmental entity shall seek written affirmations from all offerers as to the offerer’s understanding of and agreement to comply with the governmental entity’s procedures relating to permissible contacts during a governmental procurement pursuant to subdivision three of this section.