SuffolkCompliance.pdf

SUFFOLK COUNTY COMPLIANCE FORMS

USING YOUR COMPUTER, TYPE IN THE INFORMATION ON THIS SHEET. THE INFORMATION ON THIS SHEET WILL

AUTOMATICALLY POPULATE THROUGHOUT ALL OF THE FOLLOWING DOCUMENTS.

PLEASE BE SURE TO FILL IN ANY REMAINING INFORMATION IN THESE DOCUMENTS.

CONTRACT INFORMATION

BID NUMBER:

TITLE:

BRIEF DESCRIPTION OF PROJECT/SERVICE:

CONTRACT AMOUNT: AWARDING DEPT/AGENCY:

PROJECTED STATE DATE: PROJECTED END DATE:

COMPANY NAME, ADDRESS, AND CONTACT INFORMATION

COMPANY NAME:

CURRENT ADDRESS:

CITY, STATE: ZIP CODE:

CONTACT NAME: TITLE: PHONE NUMBER:

EMAIL: TAXPAYER OR FEDERAL ID:

MAIL YOUR ORIGINAL COMPLETED NOTARIZED FORMS TO :

Requester's Name 335 YAPHANK AVENUE - YAPHANK, NY 11980 rpierro Typewritten Text rpierro Typewritten Text

REV 1/6/22

rpierro Typewritten Text rpierro Typewritten Text rpierro Typewritten Text rpierro Typewritten Text rpierro Typewritten Text rpierro Typewritten Text rpierro Typewritten Text

Krista Cusimano Cross-Out

Edward P. Romaine Suffolk County Executive

Wayne T. Rogers Commissioner

SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING, & CONSUMER AFFAIRS

DOL-LHE1-2 Revised 1/24

NOTICE OF APPLICATION TO CERTIFY COMPLIANCE WITH FEDERAL LAW (8 U.S.C. SECTION 1324A) WITH RESPECT TO

LAWFUL HIRING OF EMPLOYEES, Suffolk County Code, Chapter 353 (2006)

To Be Completed By Applicant/Covered Employer/Owner

EMPLOYER/CORP/BUSINESS/COMPANY NAME: _______________________________________________________________________

ADDRESS: ___________________________________________________________________________________________________________

CONTACT NAME: ___________________________ TELEPHONE #: ___________________ AWARDING AGENCY: _______________

VENDOR, FEDERAL ID OR SOCIAL SECURITY #: _______________________________ CONTRACT ID: ________________________

NOT-FOR-PROFIT: YES_____ NO_____ (Submit Proof of IRS Not-for-Profit Status)

TERM OF CONTRACT OR EXTENSION (PROVIDE DATES): _____________________________

BRIEF DESCRIPTION OF COMPENSATION, PROJECT OR SERVICE: _____________________________________________________

SUBCONTRACTOR NAME: ____________________________________________________________________________________________

ADDRESS: ___________________________________________________________________________________________________________

VENDOR, FEDERAL ID OR SOCIAL SECURITY #: _______________________________ TELEPHONE #: _______________________

CONTACT NAME: ________________________ DESCRIPTION OF COMPENSATION, PROJECT OR SERVICE: __________________

EVIDENCE OF COMPLIANCE:

Copies of the following must be maintained by covered employers or the owners thereof for each employee for the time periods set forth in Suffolk County

Code, Section 353-14 (A):

A. United States passport; or

B. Resident alien card or alien registration card; or

C. Birth certificate indicating that person was born in the United States; or

D. (1) A driver’s license, if it contains a photograph of the individual; and

(2) A social security account number card (other than such a card which specifies on its face that the issuance of the card does not authorize employment in the United States); or

E. Employment authorization documents such as an H-1B visa, H-2B visa, and L-1 visa, or other work visa as may be authorized by the United States Government at the time the County contract is awarded for all covered employees.

AFFIDAVIT OF COMPLIANCE WITH THE REQUIREMENTS OF

8 U.S.C. SECTION 1324a WITH RESPECT TO LAWFUL HIRING OF EMPLOYEES

State of New York ) ss:

County of ______________________)

______________________________, being duly sworn, deposes and says:

(Print Name of Deponent)

1. I am owner/authorized representative of ________________________________________________________________.

(Circle one) (Name of Corp., Business, Company)

2. I certify that I have complied, in good faith, with the requirements of Title 8 of the United States Code (U.S.C.) section 1324a (Aliens and

Nationality) with respect to the hiring of covered employees and with respect to the alien and nationality status of the owners thereof, as set forth in Suffolk County Code Chapter 353 (2006).

Sworn to before me this _____ day (Signature of Deponent) of ________________, 20______

(Notary Public)

Rev. 5/2013

Suffolk County Form 22 Contractor’s/Vendor’s Public Disclosure Statement

Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement must be completed by all Contractors/vendors that have a Contract with Suffolk County, with the exception of hospitals;

educational or governmental entities; not-for-profit corporations; and Contracts providing foster care, family day care providers, or child protective consulting services, who do not have to fill out this form at all.

1. Contractor’s/Vendor’s Name_____________________________________________________________

Address_____________________________________________________________________________

City and State________________________________________________Zip Code__________________

2. Contracting Department’s Name___________________________________________________________

Address______________________________________________________________________________

3. Payee Identification or Social Security No.___________________________________________________

4. Type of Business: _____Corporation _____Partnership _____Sole Proprietorship _____Other

5.a Is Contractor/vendor entering into or has Contractor/vendor entered into a Contract with Suffolk County in excess of $1,000? _____Yes _____No.

5.b Has Contractor/vendor entered into three or more Contracts, including the one for which you are now completing this form, with Suffolk County, any three of which, when combined, exceed $1,000?

____Yes ____No.

6. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Board of Directors or comparable body, names and addresses of all partners, and names and addresses of all corporate officers. Conspicuously identify any person in this table of organization who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary.)

7. List all names and addresses of those individual shareholders holding more than five percent (5%) interest in the Contractor/vendor. Conspicuously identify any shareholder who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary).

8. Does Contractor/vendor derive 50% or more of its total revenues from its contractual or vendor relationship with Suffolk County? ____Yes ____No.

9. If you answered yes to 8 above, you must submit with this disclosure statement, a complete financial statement listing all assets and liabilities as well as a profit and loss statement. These statements must be certified by a Certified Public Accountant. (Strike this out if not applicable.)

10. The undersigned shall include this Contractor’s/Vendor’s Public Disclosure Statement with the Contract. (Describe general nature of the Contract ____

11. Remedies. The failure to file a verified public disclosure statement as required under local law shall constitute a material breach of Contract. Suffolk County may resort, use or employ any remedies contained in Article II of the Uniform Commercial Code of the State of New York. In addition to all legal remedies, Suffolk County

Rev. 5/2013 shall be entitled, upon a determination that a breach has occurred, to damages equal to fifteen percent (15%) of the amount of the Contract.

12. Verification. This section must be signed by an officer or principal of the Contractor/vendor authorized to sign for the company for the purpose of executing Contracts. The undersigned being sworn, affirms under the penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to his/her own knowledge, true.

Dated: ______________ Signed: __________________________________________________________ Printed Name of Signer: __________________________________________________________ Title of Signer: __________________________________________________________ Name of Contractor/Vendor: __________________________________________________________

UNIFORM CERTIFICATE OF ACKNOWLEDGMENT

(Within New York State)

STATE OF NEW YORK)

COUNTY OF ) ss.:

On the ____ day of ______________ in the year _____ before me, the undersigned, personally appeared ____________________ personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

(Signature and office of individual taking acknowledgement) (Notary Public)

UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT

(Without New York State)

STATE OF )

)ss.:

COUNTY OF )

On the________day of___________________ in the year ______before me, the undersigned, personally appeared_________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument, and that such individual(s) made such appearance before the undersigned in (Insert the city or other political subdivision and the state or country or other place the acknowledgement was taken)

(Signature and office of individual taking acknowledgement) (Notary Public)

Form 22 – Contractor/Vendor’s Public Disclosure Statement continued….

Certification Regarding Lobbying for Contracts, Grants, Loans and Cooperative Agreements

The undersigned certifies, to the best of his or her knowledge and belief, that:

1. No State or Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence legislation or appropriation actions pending before local, State and Federal executive and/or legislative bodies in connection with the awarding of any contract, the making of any grant, the making of any loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any contract, grant, loan, or cooperative agreement.

2. If any funds other than State of Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence legislation or appropriation actions pending before local, State and Federal executive and/or legislative bodies in connection with this contract, grant, loan or cooperative agreement, the undersigned shall complete and submit

Standard Form LLL, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Failure to file the required certification shall be subject to civil penalty by the Federal government of not less than $10,000 and not more than $100,000 for each such failure.

Provider: ________________________________________

Agreement Number:____________________________________

Sign: _________________________________________

Name: _________________________________________

Title: _________________________________________

Date: _________________________________________

DISQUALIFICATION OF NONRESPONSIBLE BIDDERS

PURSUANT TO CHAPTER 189, ARTICLE II OF THE SUFFOLK COUNTY CODE, THE

FOLLOWING IS TO BE COMPLETED BY ALL BIDDERS/CONTRACTORS.

The authorized signatory for the entity signing this document acknowledges that s/he has read and is familiar with the provisions of Chapter 189, Article II of the Suffolk County Code which applies to the subject contract. For the purposes of this form, the terms “entity” and “convicted of” shall have the meanings set forth in section 189-4 of Chapter 189.

Has the entity, at any time during the ten years preceding the date of submission of the bid, been convicted of committing or attempting to commit an offense(s) relating to any of the following: extortion; coercion; bribery; theft; fraud; any violent crime relating to business, labor or commerce; sabotage, collusive bidding/bid rigging; any environmental crime including, but not limited to, the illegal use or disposal of toxic/hazardous waste or chemicals; combination in restraint of trade; conspiracy to commit one of these crimes;

and/or criminal solicitation associated with one of the crimes listed above?

Yes No

If the answer to question 2 above is “Yes” the entity shall be determined to be a “non-responsible bidder” and disqualified from bidding on the County project or contract.

List all criminal convictions, dates of conviction, and courts of conviction rendered upon the entity, whether upon a verdict or plea of guilty or nolo contendere, within the ten years preceding the date of submission of the bid. Use a separate sheet if more space is necessary.

Is the entity currently in compliance with applicable Suffolk County licensing laws if it has, or is required to have, a license issued by Suffolk County?

Yes No

If the answer to question 5 above is “No” the entity shall be determined to be a “non-responsible bidder” and disqualified from bidding on the County project or contract until the entity is in compliance with all applicable County licensing laws.

OFFENSE DATE OF CONVICTION COURT

chaley Typewritten Text chaley Typewritten Text chaley Typewritten Text chaley Typewritten Text chaley Typewritten Text 1.

chaley Typewritten Text 2.

chaley Typewritten Text 3.

chaley Typewritten Text 4.

chaley Typewritten Text chaley Typewritten Text 5.

chaley Typewritten Text 6.

chaley Typewritten Text chaley Typewritten Text

Rev. 8/8/17

FORM LL52-2012

Has the entity, at any time during the ten years preceding the date of submission of the bid, been convicted under, or determined by the New York State Department of Labor or the Suffolk County Department of Labor to be in violation of Chapter 31 of the New York State Labor Law, Chapter 575 of the Suffolk County Code, or any provision of State or local law protecting workers’ safety?

Yes No

If the answer to question 7 above is “Yes” please provide detailed information, on a separate sheet, regarding the violation(s), history of previous violation(s), and such other factors which the awarding agency may give due consideration when determining whether to disqualify the entity as a nonresponsible bidder.

In the event the entity claims an exemption from the provisions of Chapter 189, Article II under section 189-9, provide the relevant written documentation of the request or command issued by the appropriate official of the United States Government.

Any contract entered into in violation of Chapter 189, Article II shall be null and void and any entity entering into such contract shall not be entitled to any compensation pursuant to said contract.

Any intentional or knowing misrepresentation made pursuant to the requirements of Chapter 189, Article II shall constitute an unclassified misdemeanor, and the person making such intentional or knowing misrepresentation shall be subject to punishment of a fine of $1,000 and/or up to one year of imprisonment and shall be barred from bidding on future County contracts. Each such violation shall constitute a separate and distinct offense.

I, __________________________________hereby declare under penalty of perjury under the Laws of the State of New York that I am authorized to provide this certification and that the above is true and correct.

Name of Entity

Signature of Authorized Representative Date

Print Name and Title of Authorized Representative chaley Typewritten Text LL52-2012 Form continued chaley Typewritten Text

9. Is the entity currently identified on a list established by the State of New York, pursuant to Executive Order No. 157-2016, as an institution or company that boycotts Israel?

____ Yes _____No chaley Typewritten Text chaley Typewritten Text chaley Typewritten Text chaley Typewritten Text 7.

chaley Typewritten Text 8.

chaley Typewritten Text 10.

chaley Typewritten Text 11.

chaley Typewritten Text 12.

Statement of Non-Collusion in Bids or Proposals [General Municipal Law §103-d]

By submission of this bid, each Bidder/Proposer and each person signing on behalf of any Bidder certifies, and in the case of a joint bid, each party thereto certifies as to its own organization, under penalty of perjury, that to the best of their knowledge and belief:

1. The prices in this bid have been arrived at independently without collusion, consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other Bidder/Proposer or with any competitor;

2. Unless otherwise required by law, the prices which have been quoted in the bid have not been knowingly disclosed by the Bidder/Proposer and will not knowingly be disclosed by the Bidder/Proposer prior to opening directly or indirectly to any other Bidder/Proposer or to any competitor; and

3. No attempt has been made or will be made by the Bidder/Proposer to induce any other person, partnership or corporation to submit or not to submit a bid for the purpose of restricting competition.

No bid/proposal will be considered for award nor shall any award be made where paragraphs 1, 2, and 3 above have not been complied with; provided however, that if in any case the bidder/proposer cannot make the foregoing certification, the bidder/proposer shall so state and shall furnish with the bid/proposal a signed statement which sets forth in detail the reasons therefor. Where paragraphs 1, 2 and 3 above have not been complied with, the bid/proposal shall not be considered for award nor shall any award be made unless the County determines that such disclosure was not made for the purpose of restricting competition.

The fact that a Bidder/Proposer: a) has published price lists, rates, or tariffs covering items being procured, b) has informed prospective customers of proposed or pending publication of new or revised price lists for such items, or c) has sold the same items to other customers at the same prices being bid/proposed does not constitute, without more, a disclosure hereunder.

I, __________________________________hereby affirm under penalty of perjury under the Laws of the State of New York that I am authorized to provide this certification and that the above is true and correct.

Name of Entity

Signature of Authorized Representative Date

FTS Form chaley

Rev. 7/9/13

Edward P. Romaine Suffolk County Executive

Wayne T. Rogers Commissioner

SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS

UNION ORGANIZING CERTIFICATION/DECLARATION – SUBJECT TO AUDIT

If the following definition of “County Contractor” (Union Organizing Law Chapter 803) applies to the contractor’s/beneficiary’s business or transaction with Suffolk County, the contractor/beneficiary must complete Sections I, III, and IV below. If the following definitions do not apply, the contractor/beneficiary must complete Sections II, III and IV below. Completed forms must be submitted to the awarding agency.

County Contractor: “Any employer that receives more than $50,000 in County funds for supplying goods or services pursuant to a written contract with the County of Suffolk or any of its agencies; pursuant to a Suffolk County grant; pursuant to a Suffolk County program;

pursuant to a Suffolk County reimbursement for services provided in any calendar year; or pursuant to a subcontract with any of the above.”

Section I

The Union Organizing Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk County

Local Law No. 26-2003, the Suffolk County Union Organizing Law (the law) and, as to the goods and/or services that are the subject of the contract with the County of Suffolk shall not use County funds to assist, promote, or deter union organizing (Chapter 803-3), nor seek reimbursement from the County for costs incurred to assist, promote, or deter union organizing.

I/we further agree to take all action necessary to ensure that County funds are not used to assist, promote, or deter union organizing.

I/we further agree that I/we will not use County property to hold meetings to assist, promote, or deter union organizing.

I/we further agree that if any expenditures or costs incurred to assist, promote, or deter union organizing are made, I/we shall maintain records sufficient to show that no County funds were used for those expenditures and, as applicable, that no reimbursement from County funds has been sought for such costs. I/we agree that such records shall be made available to the pertinent County agency or authority, the County Comptroller, or the County Department of Law upon request.

I/we further affirm to the following as to the goods and/or services that are the subject of the contract with the County of

Suffolk:

I/we will not express to employees any false or misleading information that is intended to influence the determination of employee preferences regarding union representation;

I/we will not coerce or intimidate employees, explicitly or implicitly, in selecting or not selecting a bargaining representative;

I/we will not require an employee, individually or in a group, to attend a meeting or an event that is intended to influence his or her decision in selecting or not selecting a bargaining representative;

I/we understand my/our obligation to limit disruptions caused by pre-recognition labor disputes through the adoption of non-confrontational procedures for the resolution of pre-recognition labor disputes with employees engaged in the production of goods or the rendering of services for the County; and

I/we have or will adopt any or all of the above-referenced procedures, or their functional equivalent, to ensure the efficient, timely, and quality provision of goods and services to the County. I/we shall include a list of said procedures in such certification.

Section II

The Union Organizing Law does not apply to this contract for the following reason(s):

DOL-L01 Revised 1/24

Check if

Applicable

Check if

Applicable http://ecode360.com/14955769#./14955795?&_suid=136620947541408664209829163062 http://ecode360.com/14955769#./14955795?&_suid=136620947541408664209829163062

DOL-L01 Revised 1/24

Section III

Contractor Name: _______________________________________________ Federal Employer ID#: __________________

Contractor Address: ________________________________________________ Amount of Assistance: _________________

________________________________________________ Vendor #: ___________________________

Contractor Phone #: ________________________________________________

Description of project or service: _______________________________________________________________________________

Section IV

In the event any part of the Union Organizing Law, Chapter 803 of the Laws of Suffolk County, is found by a court of competent jurisdiction to be preempted by federal and/or state law, this certification/declaration shall be void ab initio.

Section V

I declare under penalty of perjury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and that the above is true and correct.

Authorized Signature Date

Print Name and Title of Authorized Representative

Ed Romaine Wayne T. Rogers

Suffolk County Executive Commissioner

SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS

DOL-LW1/38 (Revised 1/26)

NOTICE OF APPLICATION FOR COUNTY COMPENSATION

LIVING WAGE CERTIFICATION/DECLARATION – SUBJECT TO AUDIT

If either of the following definitions of ‘compensation’ (Living Wage Law Chapter 575 – 2) applies to the contractor’s/recipient’s business or transaction with Suffolk County, the contractor/recipient must complete Sections 1, 3, 4 below. If the following definitions do not apply, the contractor/recipient must complete Sections 2, 3 and 4 below. Completed forms must be submitted to the awarding agency.

“Any grant, loan, tax incentive or abatement, bond financing subsidy or other form of compensation of more than $50,000 which is realized by or provided to an employer of at least ten (10) employees by or through the authority or approval of the County of Suffolk,” or

“Any service contract or subcontract let to a contractor with ten (10) or more employees by the County of Suffolk for the furnishing of services to or for the County of Suffolk (except contracts where services are incidental to the delivery of products, equipment or commodities) which involve an expenditure equal to or greater than $10,000. For the purposes of this definition, the amount of expenditure for more than one contract for the same service shall be aggregated. A contract for the purchase or lease of goods, products, equipment, supplies or other property is not ‘compensation’ for the purposes of this definition.”

Section I

The Living Wage Law applies to this contract. I/we hereby agree to comply with all the provisions of Suffolk County

Local Law No. 12-2001, the Suffolk County Living Wage Law (the Law) and, as such, will provide to all full, part-time or temporary employed persons who perform work or render services on or for a project, matter, contract or subcontract where this company has received compensation, from the County of Suffolk as defined in the Law (compensation) a wage rate of no less than $17.86 per hour worked with health benefits, as described in the Law, or otherwise $18.02 per hour or the rates as may be adjusted annually in accordance with the Law. (Chapter 575-3 B)

I/we further agree that any tenant or leaseholder of this company that employs at least ten (10) persons and occupies property or uses equipment or property that is improved or developed as a result of compensation or any contractor or subcontractor of this company that employs at least ten (10) persons in producing or providing goods or services to this company that are used in the project or matter for which this company has received compensation shall comply with all the provisions of the Law, including those specified above. (Chapter 575-2)

I/we further agree to permit access to work sites and relevant payroll records by authorized County representatives for the purpose of monitoring compliance with regulations under this Chapter of the Suffolk County Code, investigating employee complaints of noncompliance and evaluating the operation and effects of this Chapter, including the production for inspection & copying of payroll records for any or all employees for the term of the contract or for five (5) years, whichever period of compliance is longer. All payroll and benefit records required by the County will be maintained for inspection for a similar period of time. (Chapter 575-7 D)

The Suffolk County Department of Labor, Licensing & Consumer Affairs shall review the records of any Covered Employer at least once every three years to verify compliance with the provisions of the Law. (Chapter 575-4 C)

IMPORTANT! IF SECTION I IS CHECKED, APPLICANT MUST PROVIDE THE FOLLOWING INFORMATION:

Projected Wage Levels:

Complete the chart below listing hourly wage rates, number of hours worked per week, compensated days off received yearly and indicate if medical benefits are received for each employee dedicated to fulfilling the terms of this contract.

Note: Complete the following chart only if the Living Wage Law applies and if Section I above is checked.

Employee Name and Title

Hourly

Wage

Rate

Works less than 20 hours per week

(Yes or No)

Works 20 hours or more per week

(Yes or No)

Employee actually receives health benefits

(Yes or No)

Full-time employees receive at least 12 compensated days off per year. Part-time employees receive prorated compensated time off in increments proportional to full-time employees (Yes or No)

Section II The Living Wage Law does not apply to this contract for the following reason(s): (Please check all that apply to this contract.)

Employ less than 10 employees Grant, loan, tax incentive or abatement, Amount of Compensation is less than $10,000.

Do not have any employees working in bond subsidy or other form of for the furnishing of services

Suffolk or Nassau Counties compensation is $50,000 or less. Other:

No cost to Suffolk County Pay prevailing wage rates

Section III Contractor Name: __________________________________________ Federal Employer ID or SSN#: ___________________________

Contractor Address: _____________________________________________________ Amount of Compensation: _________________________________

_____________________________________________________________________ Term of Contract: ________________________________________

Contact Name: __________________________ Contractor Phone # ___________________ Awarding Agency: _______________________________

Contract ID #: ______________________________________ Description of project or service: ____________________________________________

Section IV I declare under penalty of perjury under the Laws of the State of New York that the undersigned is authorized to provide this certification, and that the above is true and correct.

Authorized Signature Date

Print Name and Title of Authorized Representative

Check if applicable

Check if applicable