T203097 - RFQ (Final).pdf
PDF 291 KB Posted
- Attached to
- Furniture Moving Services
- Solicitation number
- 2136265
- Issued by
- Queens County, New York
About this file
This is a Request for Quote (RFQ) issued by the New York State Office of Mental Health (OMH) for furniture moving services at Creedmoor Psychiatric Center located in Queens Village, New York. The procurement involves two phases: temporary relocation of office, studio, program, and museum operations to a temporary space, and subsequent return relocation to the renovated facility. The scope of work includes all labor, equipment, materials, transportation, packing, and moving services necessary to disassemble, pack, load, transport, unload, reassemble, and place 276 pieces of inventory including amplifiers, easels, tables, chairs, desks, keyboards, flat-screen televisions, and miscellaneous museum and studio materials. An optional site visit is scheduled for Thursday, July 2, 2026, at 10:00 a.m., with questions due by July 9, 2026, at 3:00 p.m. Answers to questions will be provided by July 16, 2026. Quote submissions are due Thursday, July 23, 2026, by 3:00 p.m., with an anticipated contract term of September 1, 2026, through August 31, 2027.
The RFQ is designated as a discretionary "T" contract, with award based on lowest cost, reasonableness of price, and justification for vendor selection. Prevailing wage requirements apply per Prevailing Rate Case Number 2026901085. Contractors must provide Workers' Compensation, Disability Benefits, and General Liability insurance with OMH and Creedmoor Psychiatric Center named as additional insureds. MWBE participation goals are established at 30 percent overall (16 percent MBE and 14 percent WBE), with a 6 percent SDVOB goal. Background checks against the Staff Exclusion List and Statewide Child Abuse Registry are required for all contractors and their employees with regular and substantial contact with facility patients. All contractors must execute the Justice Center Code of Conduct acknowledgement form and comply with New York State Finance Law Sections 139-j and 139-k regarding procurement lobbying restrictions. Electronic payment through the NYS Office of the State Comptroller is mandatory for contract payments unless expressly authorized otherwise by OMH.
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| (Updated) T203097 - RFQ - Furniture Moving Services.pdf | ||
| T203097 - Addendum 1.pdf |
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NYS OFFICE OF MENTAL HEALTH
REQUEST FOR QUOTE (RFQ) #: OMH01-T203097-3650275
FOR THE PROCUREMENT OF: Furniture Moving Services for Creedmoor Psychiatric Center
KEY EVENTS
Optional Site Visit Thursday, July 2, 2026 at 10:00am
Receipt of Questions from Potential Offerors Thursday, July 9, 2026 by 3:00pm
Questions and Answers sent by OMH Thursday, July 16, 2026
Quote Submission Due Date: Thursday, July 23, 2026 by 3:00pm
Anticipated Start/End dates: September 1, 2026 - August 31, 2027
Issuing Office/Permissible Contacts: The issuing office, named below, is the sole point of contact in the State for matters related to this transaction. Pursuant to NY State Finance Law 139-j and 139-k, this transaction includes and imposes certain restrictions on communications between OMH and an offeror during the procurement process. Please reference Attachment J, Summary of OMH Procurement Lobbying Guidelines, included with this Request for Quote.
Primary Contact:
Attention: Brendan Perperian
Address: 75 New Scotland Avenue, Albany NY 12208
Phone: (518) 549-1734
E-Mail: Brendan.Perperian@omh.ny.gov
Secondary Contact:
Attention: Chairmona Mayo
Phone: (518) 549-5210
E-Mail: Chairmona.Mayo@omh.ny.gov
1. Introduction: OMH is seeking quotes for Furniture Moving Services at Creedmoor Psychiatric Center, located at 79-25 Winchester Boulevard, Queens Village, New York 11427-2199
2. Scope of work:
Project: Temporary Relocation and Return Relocation of Office, Studio, Program, and Museum Operations
Summary:
Provide all labor, equipment, materials, transportation, packing and moving services necessary to temporarily relocate operations from the existing location to a temporary space and subsequently return all contents to the renovated facility.
Phase 1- Temporary Relocation Move
1. Provide all necessary moving labor, trucks, equipment, dollies, carts, moving supplies and materials.
2. Disassemble (if required), packing and loading of all inventoried items from the origin location.
3. Transporting, unloading and placement of furniture, equipment, artwork, supplies, archives, and program materials to the temporary location.
4. Reassemble of all furniture, equipment and materials, placement of all furniture, equipment, and boxes according to approved floor plans in its designated rooms and work areas.
5. Remove all packing debris generated by the move.
Phase 2- Return Relocation (Move Back)
1. Provide all necessary moving labor, trucks, equipment, dollies, carts, moving supplies and materials.
2. Disassemble (if required), repack and load all contents at the temporary location.
3. Transport all furniture, equipment, artwork, supplies, archives, and program materials back to the permanent location.
4. Reassemble, unload and place all items according to the final approved floor plan.
5. Return all contents to designated offices, studios, galleries, classrooms, and storage areas.
6. Remove and dispose of all packing materials and moving debris generated by the move.
Special Requirements
1. Provide required Worker’s Comp, Disability and General Liability insurance coverage and certificates naming the facility and governing agency as additional insureds.
2. Comply with all applicable safety, security, and facility access requirements.
Deliverables
• Relocation project plan
• Pack and protect contents
• Temporary relocation completion to be approved by (Designated Creedmoor representative)
• Return relocation completion to be approved by (Designated Creedmoor representative)
• Furniture to be placed according to approved floor plans in its designated rooms and work areas.
• Final walkthrough and acceptance by facility representatives
Inventory / Articles List of Items to be Packed, Moved, and Reinstalled
Item Quantity
Amplifiers 5
Easels 15
Tables (3' x 3') 4
Tables (5' x 2') 8
Small Boxes/Cartons (1.5 cu. ft.) 100
Medium Boxes/Cartons 30
Wardrobe Boxes/Cartons 5
Folding Chairs 8
Straight/Office Chairs 65
Drafting Tables 6
Drum Set 1
Miscellaneous museum, studio, office, and program materials 1
Music Keyboards 2
Office Desks 12
High-Top Table 1
Tables (other) 11
Flat Screen TVs (30"–50") 2
Total Inventory: 276 pieces
Background Checks and Requirements for Contractor providing services in OMH-operated
Facilities:
A. If the CONTRACTOR is providing services described in the Scope of Work, in his or her individual capacity such that the CONTRACTOR will have regular and substantial contact with any person who is receiving services or support from OMH:
1) CONTRACTOR agrees to be screened by OMH against the Staff Exclusion List (“SEL”) and Statewide Child Abuse Registry List (“SCR”) in accordance with Social Services Law Sections 424-a and 495. In the event that SCR notifies OMH of the existence of an indicated report, CONTRACTOR agrees to provide written consent to the SCR to release to OMH any and all information SCR has regarding CONTRACTOR. CONTRACTOR shall provide such additional information as OMH, in its sole discretion, deems necessary to permit OMH to make a determination about CONTRACTOR’s suitability to provide the contract services. Any fees associated with this procedure will be paid by the OMH Facility.
2) By signing into a Contract Agreement, CONTRACTOR represents and warrants that:
i. CONTRACTOR has not previously engaged in any act in violation of any law which could compromise the health and safety of Facility patients.
ii. During the term of this Agreement, CONTRACTOR shall not engage in any act in violation of any law which could compromise the health and safety of Facility patients.
3) Prior to being permitted to provide services under this Agreement, CONTRACTOR shall execute the Code of Conduct | Justice Center for the Protection of People With Special Needs as required by the Protection of People with Special Needs Act. A copy of the Justice Center Code of Conduct can be found at the following link: code-of-conduct-acknowledgement-form_feb-2021.pdf.
4) OMH may terminate the Agreement for cause immediately in the event that:
i. CONTRACTOR is listed on the SEL;
ii. CONTRACTOR fails to provide consent for release of information from SCR as required in subparagraph (a) above;
iii. CONTRACTOR fails to provide such additional information as OMH, in its sole discretion, deems necessary to permit OMH to make a determination about CONTRACTOR’s suitability to provider for the contract services;
iv. OMH, in its sole and absolute discretion, determines that CONTRACTOR is not suitable to provide the contract services based on information in the SCR or supplemental information provided by CONTRACTOR;
v. OMH receives reliable information that, prior or during the term of the Agreement, CONTRACTOR has engaged in an act in violation of the law which, in OMH’s sole and absolute discretion, could compromise the health and safety of Facility patients;
5) CONTRACTOR fails to execute, or following execution, to comply with the required code-of-conduct-acknowledgement-form_feb-2021.pdf
6) Prior to terminating the Agreement for cause as provided in subparagraph D(3)-(6) above, OMH shall provide CONTRACTOR with written notice and an opportunity to be heard. Contractor shall be suspended from performing services under the Agreement pending OMH’s final determination regarding termination.
B. If the CONTRACTOR provides the services described in the Scope of Work, via employees, agents, or subcontractors (subject individuals), wherein the subject individuals will have regular and substantial contact with any person who is receiving services or supports from OMH:
1) CONTRACTOR shall assure that the subject individuals agree to be screened by OMH against the SEL and SCR in accordance with Social Services Law Sections 424-a and 495. In the event that SCR notifies OMH of the existence of an indicated report, CONTRACTOR agrees that subject individual must provide written consent to the SCR to release to OMH any and all information SCR has regarding the subject individual. CONTRACTOR shall ensure that subject individuals provide such additional information as OMH, in its sole discretion, deems necessary to permit OMH to make a determination about subject individual’s ability to provide services to OMH patients. Any fees associated with this procedure will be paid by the OMH Facility.
2) CONTRACTOR, solely at its own expense, shall pre-screen and conduct background checks which shall consist of an investigation to determine evidence of criminal history; verification of education, professional license, certification or other credentials required. CONTRACTOR assumes responsibility for ensuring that no subject individual has previously engaged in any act in violation of any law which could compromise the health and safety of Facility patients.
https://www.justicecenter.ny.gov/code-conduct https://www.justicecenter.ny.gov/system/files/documents/2021/02/code-of-conduct-acknowledgement-form_feb-2021.pdf https://www.justicecenter.ny.gov/system/files/documents/2021/02/code-of-conduct-acknowledgement-form_feb-2021.pdf https://www.justicecenter.ny.gov/system/files/documents/2021/02/code-of-conduct-acknowledgement-form_feb-2021.pdf
3) CONTRACTOR must assure that subject individuals agree to read and sign the code-of-conduct-acknowledgement-form_feb-2021.pdf. OMH reserves the right to bar any subject individual from performing contract services under this Agreement in the event that such individual fails to meet the requirements set forth herein. OMH may terminate the Agreement for cause immediately in the event that CONTRACTOR is unable to provide services to the OMH facility via a subject individual who has complied with all requirements identified in items (i) – (iii) above.
3. Site Visit: There is an optional site visit scheduled for Thursday, July 2, 2026 at 10:00am at Creedmoor
Psychiatric Center, located at 79-25 Winchester Boulevard, Queens Village, New York 11427-2199. No one will be admitted to the conference or site visit after the time cited above.
Conference & Site visit registration can be accomplished by completing and sending the Site Visit Registration Form, Attachment C via email to Brendan.perperian@omh.ny.gov, with a cc. to Chairmona.mayo@omh.ny.gov no later than Wednesday, July 1, 2026 by 3:00pm.
4. Method of Award: As per NYS Finance Law and NYS Procurement Council Guidelines, this RFQ will result in a Discretionary "T" contract. Selection will be based upon lowest cost, reasonableness of price and justification for vendor selection.
5. Quote Submission:
The Quote Submission, Attachment D, must be submitted via email to Brendan.Perperian@omh.ny.gov, with a cc’ to Chairmona.Mayo@omh.ny.gov no later than Thursday, July 23, 2026 by 3:00pm
6. Quote Requirements:
A. The submission of a quote constitutes a binding offer. Such binding offer shall be firm and not revocable for a period of one hundred and twenty (120) days after the deadline for a quote submission.
B. The quote is to be submitted via email only to Brendan.Perperian@omh.ny.gov on or before the date and time defined by this RFQ. No late submissions will be considered.
7. Procurement Lobbying Law Requirements: Does apply to this RFQ.
Upon notification of selection, the awardee will be required to complete the two forms listed below:
1. Attachment J-1: Offeror’s Affirmation of Understanding
2. Attachment J-2: Offeror Disclosure of Prior Non-Responsibility Determinations
8. Consultant Disclosure Legislation: Does Not apply to this RFQ.
Upon notification of selection, the awardee will be required to complete the Consultant Disclosure Form A.
9. New York State Worker Compensation (WC) & Disability Benefits (DB) insurance Requirements:
Upon notification of selection, the awardee will be required to provide current WC and BD certificates or WC and DB Exemption certificate.
10. Liability Insurance Requirement:
Upon notification of selection, the awardee will be required to provide current general liability insurance certificate in a form that is acceptable to OMH.
https://www.justicecenter.ny.gov/system/files/documents/2021/02/code-of-conduct-acknowledgement-form_feb-2021.pdf https://www.justicecenter.ny.gov/system/files/documents/2021/02/code-of-conduct-acknowledgement-form_feb-2021.pdf mailto:Chairmona.mayo@omh.ny.gov
11. Prevailing Wage: Does apply to this RFQ.
The Prevailing Rate Case (PRC#) number is:2026901085, requested on: 6/15/2026.
A copy of the prevailing wage schedules that apply to this Contract is available at:
https://apps.labor.ny.gov/wpp/publicViewProject.do?method=showIt&id=1623052 and is hereby incorporated by reference and made part hereto as fully as if it were set forth at length herein.
12. Minority and Women-owned Business Enterprise (MWBE) and Service Disabled Veteran-Owned Business (SDVOB) Requirements: Does apply to this RFQ.
The MWBE goal established for this solicitation is 30%. MBE: 16% and WBE 14%.
The SDVOB goal established for this solicitation is 6%.
Upon notification of selection, the awardee will be required to complete the applicable forms regarding the MWBE/SDVOB Utilization Plan(s) or Applications for Waiver as appropriate.
13. Reserved Rights of New York State:
A. Withdraw the RFQ at any time, at its sole discretion;
B. Disqualify any offeror whose conduct and/or quote submission fails to conform to the requirement of the RFQ;
C. Seek clarifications of quote;
D. Use information obtained through site visits, management interviews and the State’s investigation of an offeror’s qualifications, experience, ability or financial standing, and any material or information submitted by the offeror in response to the OMH’s request for clarifying information in the course of evaluation and/or selection under this RFQ.
E. Amend RFQ specifications to correct errors or oversights, or to supply additional information as it becomes available;
F. Change any of the scheduled dates stated herein;
G. Adjust or correct cost or cost figures with concurrence of the offeror if mathematical or typographical errors exist;
14. Quote Confidentiality:
All quotes submitted for OMH’s consideration will be held in confidence. However, the resulting contract is subject to New York State Freedom of Information Law (FOIL). Therefore, if an offeror believes that any information in its quote constitutes a trade secret or should otherwise be treated as confidential and wishes such information not to be disclosed if requested, pursuant to FOIL. (Article 6 of the Public Officer’s Law), the offeror shall submit with its quote a separate letter specifically identifying the page number(s), line(s), or other appropriate designation(s) containing such information, explaining in detail why such information is a trade secret and formally requesting that such information be kept confidential. Failure by an offeror to submit such a letter with its bid identifying trade secrets will constitute a waver by the offeror of any rights it may have under Section 89(5) of the Public Officers’ Law relating to protection of trade secrets. The proprietary nature of the information designated confidential by the offeror may be subject to disclosure if ordered by a court of competent jurisdiction. A request that an entire quote be kept confidential is not advisable since a bid cannot reasonably consist of all data subject to FOIL proprietary status.
https://apps.labor.ny.gov/wpp/publicViewProject.do?method=showIt&id=1623052
15. Contract Payment:
All contractors are required to participate in the Electronic Payment program offered by the NYS Office of the State Comptroller (OSC). Payment for invoices submitted by contractors will only be rendered electronically unless payment by paper check has been expressly authorized by OMH’s Office of Financial Management, at OMH’s sole discretion, due to extenuating circumstances. Electronic payments will be made in accordance with ordinary State procedures and practices. Contractors shall comply with the State Comptroller’s procedures to authorize electronic payments. For additional information and to apply for Electronic Payments, the CONTRACTOR is directed to the following web site:
http://www.osc.state.ny.us/epay/index.htm.
http://www.osc.state.ny.us/epay/index.htm
ATTACHMENT D
QUOTE SUBMISSION
RFQ #:OMH01-T203097-3650275
FOR THE PROCUREMENT OF: Furniture Moving Services at Creedmoor Psychiatric Center
Attention: Brendan Perperian, Brendan.Perperian@omh.ny.gov
Name of Firm: ______________________________________________________________________
Address: __________________________________________________________________________
Federal ID (FEIN) #: ______________________ NYS Vendor ID #: ____________________________
Please check all that apply:
NYS Minority-owned Business (MBE) Registration #:
NYS Women-owned Business (WBE) Registration #:
NYS Service Disabled Veteran-Owned Business
(SDVOB)
Registration #:
NYS Small Business (SB) Registration #:
NYS Disadvantaged Business Enterprise (DBE) Registration #:
None of the Above
Note: Offerors are not to change, delete, or make any additions to this form, and are to supply only the quote information that is required. If any changes, deletions, or additions are made by the bidder, or if all of the required information is not provided, then at OMH’s discretion, the quote may be disqualified.
Phase One - Temporary Relocation (Move)
Total for moving
Total for Materials
Phase One Total (Moving + Materials) =
ATTACHMENT D
QUOTE SUBMISSION
Phase Two - Relocation Return (Move Back)
Total for moving
Total for Materials
Phase One Total (Moving + Materials) =
Contract Total (Phase One + Phase Two) = _____________________
By offering a quote, vendor agrees to all terms of the RFQ; Quotes are not to include sales tax as New York State Agencies are tax-exempt.
Printed name: _____________________ Authorized signature: ____________________________
Date: ___________ E-mail address: ________________________ Phone #: ___________________
ATTACHMENT C
SITE VISIT REGISTRATION FORM
SITE VISIT DATE: Thursday, July 2, 2026, by 10:00am
Bid #: OMH01-T203097-3650275
FOR THE PROCUREMENT OF: Furniture Moving Services at Creedmoor Psychiatrice Center
PLEASE RETURN NO LATER THAN: Wednesday, July 1, 2026 by 3:00pm
# of pages including this cover sheet: 1
Today’s Date: _________________________
PLEASE SUBMIT REGISTRATION TO:
Attention: Brendan Perperian
Phone: (518) 549-1734
E-Mail: Brendan.Perperian@omh.ny.gov
FROM: COMPANY _________________________________
REPRESENTATIVE NAME _________________________________
TELEPHONE # _________________________________
FAX # _________________________________
EMAIL ADDRESS for designated contact: _________________________________
Number of attendees (maximum of two): __________
ATTACHMENT E
SOLICITATION COVER SHEET
Bid #: OMH01-T203097-3650275
FOR THE PROCUREMENT OF: Furniture Moving Services at Creedmoor Psychiatric Center
Number of Years in Business: ____ Number of Years of Experience Providing Solicited Service: ____
Form submitted to show compliance with New York State Workers Compensation Insurance requirements:
CE-200____ or C-105.2____ or U-26.3____ or SI-12____ or GSI-105.2____
Form submitted to show compliance with New York State Disability Benefits Insurance requirements:
CE-200____ or DB-120.1____ or DB-155____
PLEASE CHECK THE APPROPRIATE BOX:
NYS Minority-owned Business (MBE) Registration #
NYS Women-owned Business (WBE) Registration #
NYS Small Business (SB) Registration #
NYS Disadvantaged Business Enterprise
(DBE) Registration #
NYS Service-Disabled Veteran Owned Business (SDVOB) Registration #
None of the above
(Note: Information provided on this form should match, when applicable, to information provided on Vendor Responsibility Questionnaire/ or on the online version of the document.)
NEW YORK STATE OFFICE OF MENTAL HEALTH
ATTACHMENT J
Summary of OMH Procurement Lobbying Guidelines
OMH has issued Guidelines pursuant to the New York State Finance Law Sections 139-j and 139-k, which prohibit lobbying on procurement contracts. For purposes of the law, procurement contracts include most contracts/Purchase Orders with an estimated annual expenditure in excess of $15,000 per year, as well as amendments and modifications to such contracts which were not contemplated by the original contract and represent a material change in the scope of the contract.
The law provides that, during the Restricted Period of an agency procurement for goods or services, vendors (or offerors) may only contact the agency’s designated contact person(s), and all contacts, whether permissible or impermissible, shall be recorded:
Vendor Requirements
• Must limit communications with OMH during the Restricted Period of each procurement to the OMH-designated point(s) of contact
• The Restricted Period is the period from the date of the earliest method by which an agency solicits a response from vendors to a contract opportunity until the date the contract is awarded and, if applicable, approved by the Comptroller’s Office.
• Must affirm in writing vendor’s understanding of and agreement to comply with the OMH Procurement Guidelines
• Must certify whether vendor has been found non-responsible within the previous four years by any Governmental Entity for failure to comply with State Finance Law 139-k or for the intentional provision of false or incomplete information regarding its procurement lobbying law compliance.
OMH Requirements
• Must include a summary of OMH’s procurement lobbying guidelines in each initial solicitation document
• Must designate a single point or points of contact for each procurement
• Must require OMH staff to record all Contacts from offerors during the Restricted Period of each procurement
• A Contact is any communication with OMH under circumstances where a reasonable person would infer that the communication was intended to influence the procurement
• Must refer all impermissible Contacts for investigation by OMH
• Must make a responsibility determination with regard to State Finance Law Section 139-j and 139-k compliance prior to award of the contract
• Must include a provision in all procurement contracts which allows OMH to terminate the contract if the vendor’s certification is found to be intentionally false or intentionally complete.
ATTACHMENT J1
OFFEROR’S AFFIRMATION OF
UNDERSTANDING OF,
AGREEMENT TO,
AND COMPLIANCE WITH
OMH PROCUREMENT LOBBYING GUIDELINES
New York State Finance Law 139-j(6)(b) provides that OMH shall seek written affirmation from all Offerors on their understanding of and agreement to comply with OMH’s procedures relating to permissible contacts during each procurement pursuant to State Finance Law 139-j(3). OMH is expanding on that requirement, requiring that
(1) Offerors affirm they have complied with the OMH Guidelines throughout the procurement process, and (2) Offerors agree that OMH shall have the right to terminate any contract, purchase order or purchase authorization resulting from the procurement in the event that the affirmation is found to be intentionally false or intentionally incomplete.
Solicitation # and/or OMH descriptive name of solicitation: OMH01-T203097-3650275, Furniture Moving Services at Creedmoor Psychiatric Center
I hereby affirm that I have read and understand the OMH Procurement Lobbying Guidelines, and agree to comply with the OMH procedures relating to permissible contacts during this New York State governmental procurement pursuant to State Finance Law 139-j(3). Unless I provide notice otherwise, my execution of this affirmation shall be an ongoing representation that I have complied with, and continue to be in compliance with, the OMH Guidelines.
I understand and agree that: 1) OMH shall have the right to terminate the contract, purchase order or purchase authorization resulting from this solicitation in the event that this affirmation is found to be intentionally false or intentionally incomplete; and 2) upon such finding, OMH may exercise its termination right by providing written notification.
Date:_______________
Signature of Offeror’s Authorized Representative _______________________________
Printed Name and Title ___________________________________________________
Name of Offeror_________________________________________________________
Offeror’s Address: ______________________________________________________
OMH Attachments J1
NEW YORK STATE OFFICE OF MENTAL HEALTH
ATTACHMENT J2
OMH OFFEROR DISCLOSURE OF
PRIOR NON-RESPONSIBILITY DETERMINATIONS
New York State Finance Law 139-k requires Offerors to disclose findings of non-responsibility within the last four years by a governmental entity where such prior finding of non-responsibility was due to unlawful contacts during a procurement as stated under State Finance Law §139-j or the intentional provision of false or incomplete information to a governmental entity.
Failure to submit this form, the submission of a form with false, misleading or incomplete information, or failure to update this form when required may result in a determination of non-responsiveness and disqualification of the bid, proposal or offer. If the failure to comply is discovered after the contracting process has been completed, it may result in termination of the contract.
Solicitation # and/or OMH descriptive name of solicitation: OMH01-T203097-3650275, Furniture Moving Services at Creedmoor Psychiatric Center
(1) Has any New York State agency or authority made a finding of non-responsibility regarding the Offeror in the last four years? (Please circle): No Yes
If yes, what was the basis for the finding of the Offeror’s non-responsibility?
Please check all that apply:
__ Unlawful Contacts during a procurement contract (State Finance Law §139-j) __ The intentional provision of false or incomplete information
If yes, please provide details regarding the finding of non-responsibility below:
New York State Agency or Authority: ____________________________________ Year of Finding of Non-Responsibility:____________________________________ Facts Underlying Finding of Non-Responsibility:_____________________________ Add additional sheets if necessary
(2) Has any New York State agency or authority terminated or withheld a procurement contract with the Offeror due to the intentional provision of false or incomplete information?
(Please circle): No Yes
If yes, please provide details regarding the termination/withholding below:
New York State Agency or Authority: _____________________________________ Date of Termination/Withholding of Contract:____________Contract #: __________
Facts Underlying Termination: __________________________________________ Add additional sheets if necessary
Offeror certifies that all information provided to OMH with respect to State Finance Law 139-k is complete, true and accurate.
Date:___________ _________________________________________________
Signature of Offeror’s Authorized Representative
Printed Name and Title of Authorized Representative
Name and Address of Offeror
OMH Attachments J2
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