Statement of Disclosures.pdf

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COUNTY OF ROCKLAND - DGS-PURCHASING

BLDG. A., 6th FLOOR, 50 SANATORIUM RD, POMONA, NY 10970

TELEPHONE: 845-364-3820 / TELEFAX: 845-364-3809

STATEMENT OF REQUIRED

DISCLOSURES, REPRESENTATIONS AND CERTIFICATIONS

Note: ALL Sections on the following pages must be completed and this Statement must be signed before a Notary

Name of the Reporting Entity:

Address: ________________________________________________________________

Remit to Address if different from above:

FID No.: _________________________________

Name of Individual Completing this form: ____________________________________

Title/Position: ____________________________________________________________

Telephone Number: ________________________________

Telefax Number:__ _________________________________

EMAIL address: _____________________________________________________________________

EMAIL address (for Purchase orders to be emailed this is mandatory):

SIGNATORY FIRST & LAST NAME _____________________________________________________

SIGNATORY TITLE ___________________________________________________________________

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Section A.

AFFIDAVIT OF NON-COLLUSION

(This form must be included with bid package and initialed)

I hereby attest that I am the person responsible within my firm for the final decision as to the prices(s) and amount of this bid or, if not, that I have written authorization, enclosed herewith, from that person to make the statements set out below on his or her behalf and on behalf of my firm.

I further attest that:

1. The price(s) and amount of this bid have been arrived at independently, without consultation, communication or agreement for the purpose of restricting competition with any other contractor, bidder or potential bidder.

2. Neither the price(s), nor the amount of this bid, have been disclosed to any other firm or person who is a bidder or potential bidder on this project, and will not be so disclosed prior to bid opening.

3. No attempt has been made or will be made to solicit, cause or induce any firm or person to refrain from bidding on this project, or to submit a bid higher than the bid of this firm, or any intentionally high or non-competitive bid or other form of complementary bid.

4. The bid of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from any firm or person to submit a complementary bid.

5. My firm has not offered or entered into a subcontract or agreement regarding the purchase of materials or services from any other firm or person, or offered, promised or paid cash or anything of value to any firm or person, whether in connection with this or any other project, in consideration for an agreement or promise by an firm or person to refrain from bidding or to submit a complementary bid on this project.

6. My firm has not accepted or been promised any subcontract or agreement regarding the sale of materials or services to any firm or person, and has not been promised or paid cash or anything of value by any firm or person, whether in connection with this or any project, in consideration for my firm’s submitting a complementary bid, or agreeing to do so, on this project.

7. I have made a diligent inquiry of all members, officers, employees, and agents of my firm with responsibilities relating to the preparation, approval or submission of my firm’s bid on this project and have been advised by each of them that he or she has not participated in any communication, consultation, discussion, agreement, collusion, act or other conduct inconsistent with any of the statements and representations made in this affidavit.

The person signing this bid, under the penalties of perjury, affirms the truth thereof.

INITIAL: ________

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Section B.

ANNUAL DISCLOSURE OF POLITICAL CONTRIBUTIONS

PURSUANT TO CHAPTER 323 OF THE ROCKLAND COUNTY CODE

1. The reporting entity is (check one):

An Individual A Partnership A Corporation Municipality or Agency Not-for-profit Organization

Note: Pursuant to Chapter 323 of the Rockland County Administrative Code municipal bodies, agencies, not-for-profit organizations and entities or individuals doing less than $10,000.00 annually worth of business with the County, check off “Not Applicable” in paragraph 2 below and proceed to Section C.

2. The reporting entity (check one):

_____ Will enter into a contract with the County of Rockland, in excess of $10,000.00, which did / did not (circle one) result from public bidding.

______Is currently under a contract with the County of Rockland in excess of $10,000.00

______Not Applicable

3. The reporting entity, its members, directors, policymaking officers, or majority shareholders, have directly or indirectly made the following contributions to the persons or organizations listed below. List all contributions having a value in excess of $200.00 per year made to any political party or any individual or any committee for an individual running for public office in County of Rockland or in a district in which County of Rockland is located, for a period of 3 years prior to the date of subscribed below.

Note: Answer “none” or list each contribution separately (if necessary, use additional sheets)

Name of

Contributor

Relationship to Reporting

Entity

Contribution

Made To

Date of

Contribution

Value and Nature of Contribution

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Section C.

DISCLOSURE OF SUPPLIER RESPONSIBILITY STATEMENT

If none apply enter “None” on each line

1. List any convictions of any person, subsidiary, or affiliate of the company, arising out of obtaining, or attempting to obtain a public or private contract, or subcontract, or in the performance of such contract or subcontract.

2. List any convictions of any person, subsidiary, or affiliate of this company for offenses such as embezzlement, theft, fraudulent schemes, etc. or any other offense indicating a lack of business integrity or business honesty which affect the responsibility of the contractor.

3. List any convictions or civil judgments under state or federal antitrust statutes.

4. List any violations of contract provisions such as knowingly (without good cause) to perform, or unsatisfactory performance, in accordance with the specifications of a contract.

5. List any prior suspensions or debarments by any government agency.

6. List any contracts not completed on time.

7. List any documented violations of federal or state labor laws, regulations or standards, or occupational safety and health rules.

INITIAL: ________

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Section D.

AFFIRMATIVE ACTION PLAN CERTIFICATION

1. The subscriber below, authorized on behalf of the Reporting Entity in the title/position indicated hereinabove, states the following: (please check one box in both (a) and (b)) a.) The above-named Reporting Entity DOES or DOES NOT employ fifteen (15) or more employees AND b.) The above-named Reporting Entity

DOES transacts a minimum of $50,000 per annum business with the County of Rockland.

(i) IF SO, based on this above information, a copy of the Reporting Entity’s Affirmative

Action Plan OR

EEO (Equal Employment Opportunity) Policy is attached to this Form.

DOES NOT transacts a minimum of $50,000 per annum business with the County of Rockland.

Section E.

BUSINESS DEALINGS IN NORTHERN IRELAND -MACBRIDE PRINCIPLES

1. The subscriber below, authorized on behalf of the Reporting Entity in the title/position indicated hereinabove, certifies the following, in accordance with Article 5 of the County of

Rockland Procurement Policy: (check one) a.) The above-named Reporting Entity and any individual or legal entity in which the

Reporting Entity holds a 10% or greater ownership interest and any individual or legal entity that holds a 10% or greater ownership in the contract, either: (check, as applicable)

(i) has NO business operations in Northern Ireland

OR

(ii) must take lawful steps in good faith to conduct any business operations in Northern Ireland in accordance with the MacBride Fair

Employment Principles relating to the nondiscrimination in employment and freedom of workplace opportunity regarding such operations in

Northern Ireland, and must permit independent monitoring of their companies with such Principles.

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Section F.

CERTIFICATION OF COMPLIANCE WITH THE

IRAN DIVESTMENT ACT

Pursuant to State Finance Law §165-a, on August 10, 2012 the Commissioner of the Office of General Services (OGS) posted a prohibited entities list of "persons" who are engaged in

"investment activities in Iran" (both are defined terms in the law) on the OGS website at:

http://www.ogs.ny.gov/about/regs/docs/ListofEntities.pdf

By submitting a bid in response to a County sol ic i tat ion or by assuming the responsibility of a Contract awarded hereunder, each Bidder/Contractor, any person signing on behalf of any

Bidder/Contractor and any assignee or subcontractor and, in the case of a joint bid, each party thereto, certifies, under penalty of perjury, that once the Prohibited Entities List is posted on the

OGS website, that to the best of its knowledge and belief, that each Bidder/Contractor and any subcontractor or assignee is not identified on the Prohibited Entities List created pursuant to SFL § 165-a(3)(b).

Additionally, Bidder/Contractor is advised that once the Prohibited Entities List is posted on the

OGS Website, any Bidder/Contractor seeking to renew or extend a Contract or assume the responsibility of a Contract awarded in response to this solicitation must certify at the time the

Contract is renewed, extended or assigned that it is not included on the Prohibited Entities List.

During the term of the Contract, should the County receive information that a

Bidder/Contractor is in violation of the above referenced certification, the County will offer the person or entity an opportunity to respond. If the person or entity fails to demonstrate that he/she/it has ceased engagement in the investment which is in violation of the Act within 90 days after the determination of such violation, then the County must take such action as may be appropriate including, but not limited to, imposing sanctions, seeking compliance, recovering damages or declaring the Bidder/Contractor in default.

The County reserves the right to reject any bid or request for assignment for a Bidder/Contractor that appears on the Prohibited Entities List prior to the award of a contract and to pursue a responsibility review with respect to any Bidder/Contractor that is awarded a contract and subsequently appears on the Prohibited Entities List.

(Please check box)

1. The subscriber below, authorized on behalf of the Reporting Entity in the title/position indicated hereinabove, certifies that he/she is neither the Bidder/Contractor nor any proposed subcontractor as identified on the

Prohibited Entities List.

http://www.ogs.ny.gov/about/regs/docs/ListofEntities.pdf

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Section G.

CERTIFICATION REGARDING BOYCOTT, DIVEST

AND SANCTIONS (BDS) ACTIVITIES

1. The subscriber below, authorized on behalf of the Reporting Entity in the title/position indicated hereinabove, certifies the following, in accordance with Article 5 of the County of Rockland Procurement Policy: (check box)

The Reporting Entity/Contractor and any individual or legal entity in which the contractor/reporting entity holds a 10% (ten percent) or greater ownership interest and any individual or legal entity that holds a 10% (ten percent) or greater ownership in the contract does NOT engage in any Boycott, Divest and sanctions (BDS) activities [which activities are defined as advocating for the boycott of Israel, divestment from Israel and International sanctions against Israel, and otherwise engaging in, promoting or supporting the global campaign to increase economic and political pressure in Israel to comply with the stated goals of the BDS movement].

Section H.

ACKNOWLEDGMENT OF INSURANCE REQUIREMENTS

(Check Box to acknowledge each insurance requirement)

1. By submitting a bid/proposal in response to a County solicitation or by assuming the responsibility of a Contract awarded hereunder, each Bidder/Contractor, any person signing on behalf of any Bidder/Contractor acknowledges that they have read and understand the County’s insurance requirements as outlined in the solicitation documents.

2. Bidder/Contractor agrees to provide a valid certificate of liability with the coverages and limits outlined in this solicitation (see matrix) within five (5) business days of request and include the following:

a. The Contract/Solicitation Number and/or Purchase Order Number should be stated under the description.

b. The description must also contain a statement to the effect that “The County of

Rockland, its employees, elected officials, and affiliated municipal entities are included as additional insureds. The signing authorized representative warrants that the insurance carrier(s) have been informed of and accepted The County of Rockland as an additional insured”.

3. NYS Workman’s Compensation and NYS Disability Certificates

a. Contractor must submit valid NYS Workman’s Compensation and NYS Disability

Certificates or Attestation of Exemption with the bid/proposal.

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ACKNOWLEDGMENT OF TERMS AND CONDITIONS

Upon receipt of all required approvals a Contract must be deemed executed and created with the successful Bidder(s) upon the Commissioner's mailing or electronic communication to the address on the bid of: i) a Letter of Acceptance; or ii) a fully executed contract; or iii) a

Purchase Order authorized by the Commissioner

Print Name: _________________________________________________

Name of person responsible for this solicitation

By signing this solicitation, I acknowledge that I have downloaded, read, and accept

Appendix A - General Terms and Conditions for this solicitation

I acknowledge the receipt of _________________________ addendums

Signature: ____________________________________________________

Email Address: ________________________________________________

Direct Phone Number: __________________________________________

Fax Number: __________________________________________________

Date: __________________________________________________

NOTE: The County of Rockland dispatches authorized Purchase Orders through its eProcurement system via email.

Please provide a valid business email address (this is mandatory) to receive Purchase Orders e.g.:

• orders@

• sales @

PLEASE PRINT CLEARLY

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State of _____________________ ) ) ss:

County of ___________________)

All statements, disclosures and representations stated hereinabove this Statement Required

Disclosures, Representations and Certifications, comprised of the preceding pages, are based upon my personal review of the books and records of the reporting entity. I declare, under oath or affirmation that all of the foregoing information, as well as any supplemental responses and statements that may be attached hereto are true to the best of my knowledge. I make these statements under the penalty of perjury, in my position/title held at the above-named Reporting

Entity.

BY: ____________________________________

(Signature)

(Print Name and Title/position)

Sworn to before me this

___________day of_____________, 20

Notary Public