RFP 26-165 Disclosure Form.docx

DISCLOSURE FORM

Pursuant to the above referenced Roswell Park Cancer Institute Corporation d/b/a Roswell Park Comprehensive Cancer Center (“Roswell Park”), Request for Proposal (the “RFP”), the bidder identified on the last page of this Disclosure Form (the “Bidder”) is disclosing the following to Roswell Park:

1. Has the Bidder now and/or at any time within the past four (4) years been a party to any bankruptcy, liquidation, and/or reorganization of any kind?

|_| Yes |_| No

If yes, explain:

2. Has the Bidder had a net loss and/or negative cash flow within the past four (4) years?

|_| Yes |_| No

If yes, explain:

3. Has the Bidder failed to file any tax returns within the past four (4) years?

|_| Yes |_| No

If yes, explain:

4. Has the Bidder now and/or at any time within the past four (4) years been party to a lawsuit and/or arbitration involving any contract on which the Bidder supplied services, products, and/or materials?

|_| Yes |_| No

If yes, explain:

5. Has the Bidder ever failed to complete a project due to the fault of the Bidder and/or had a contract terminated for failure to perform?

|_| Yes |_| No

If yes, explain:

6. Is the Bidder currently involved in any pending and/or threatened litigation, either by and/or against the Bidder, arising out of any services performed and/or products and/or materials supplied by the Bidder?

|_| Yes |_| No

If yes, explain:

7. Has the Bidder been subject to investigation for a civil and/or criminal violation within the past four (4) years?

|_| Yes |_| No

If yes, explain:

8. Has the Bidder ever been suspended, debarred, and/or disqualified from doing business with any company and/or any Federal, State, and/or local government and/or governmental agency, authority, and/or official, including, but not limited to, Medicare and/or Medicaid Services (a “Governmental Entity” or “Governmental Entities”, as applicable)?

|_| Yes |_| No

If yes, explain:

9. In accordance with State Finance Law §139-k, as amended by Chapter 395 of the Laws of 2006, Chapter 501 of the Laws of 2007, Chapter 169 of the Laws of 2009 and Chapter 4 of the Laws of 2010 (which can be found at: http://ogs.ny.gov/aboutogs/regulations/advisoryCouncil/sfl139-k.htm), has any Governmental Entity made a finding of non-responsibility with regards to the Bidder within past four (4) years?

|_| Yes |_| No

If yes:

Was the basis for the finding of non-responsibility due to a violation of State Finance Law §139-j (which can be found at: http://ogs.ny.gov/aboutogs/regulations/advisoryCouncil/sfl139-j.htm)?

|_| Yes |_| No Was the basis for the finding of non-responsibility due to the intentional provision of false and/or incomplete information to any Governmental Entity?

|_| Yes |_| No

If yes:

Governmental Entity:

Details Regarding the Finding of Non-Responsibility:

10. Has any Governmental Entity ever terminated and/or withheld a contract with the Bidder due to the intentional provision of false and/or incomplete information?

|_| Yes |_| No

If yes:

Governmental Entity:

Date of Termination and/or Withholding of Contract: / / Basis of Termination and/or Withholding of Contract:

Any defined terms in the RFP shall have the same respective meanings in this Disclosure Form. The Bidder hereby warrants that by signing this Disclosure Form, it is certifying that the above statements are true and accurate as they relate to the Bidder as of the date in which this Disclosure Form is signed by the Bidder as indicated below. The Bidder understands and acknowledges that the above representations are material and important, and will be relied on by Roswell Park in awarding a Resultant Agreement. The Bidder understands and acknowledges that any misstatement in this Disclosure Form is and shall be treated as fraudulent concealment from Roswell Park of the true facts relating to the submission of the Bidder’s Bid Response.

(Bidder)

Signature

Printed Name

Title

Date

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