SUNY UPSTATE MEDICAL UNIVERSITY

VENDOR RESPONSIBILITY PACKET

Date: June 03, 2026

Contents:

Page 1 Introduction and Directions Pages 2 – 10 Vendor Responsibility Questionnaire and Certification Pages 11 - 15 New York State Finance Law 139, Public Officers Law, EO 16 and EO177 Form Page 16 Workers’ Compensation and Disability Benefits Compliance Requirements Pages 17 – 18 New York State Department of Taxation and Finance ST-220-CA Form Pages 19 – 22 SUNY Exhibit A Standard Contract Clauses Pages 23 – 28 SUNY Exhibit A-1 Affirmative Action Clauses Introduction:

Each contracting New York State Agency (e.g., SUNY Upstate Medical University) conducts a review and evaluation of prospective contractors (vendors) to provide reasonable assurances that the vendor is responsible. Also, each agency must comply with New York State Finance Law §139, New York State Public Officers Law §§73 & 74, EO 16, EO177, Workers’ Compensation and Disability Benefits coverage requirements, and New York State’s Tax Law Section 5-a. This packet is designed to provide information to assess a vendor’s authorization to do business in New York State, its business integrity, financial and organizational capacity, performance history, compliance with State Finance Law 139, EO 16, EO177, coverage of workers’ compensation and disability benefits, and whether or not a vendor is required to collect state sales and compensating use tax. This packet also contains SUNY Exhibit A Standard Contract Clauses and SUNY Exhibit A-1 Affirmative Action Clauses, which are incorporated in each contract or Purchase Order issued by SUNY Upstate Medical University (Upstate).

Directions:

All information requested in this packet must be provided and every question contained in this packet must be addressed. Where a response requires additional information, attach a written response that adequately details the requested information. Please note on each response the page and question number. The completed questionnaires, forms, and attached responses will become part of Upstate’s procurement record.

When providing additional information for an answer, your information and response should address the relationship of the issue to the proposed contract. Be brief, concise, and to the point. Discuss as appropriate, the following:

• Provide a description of the issue and identify the actions taken or currently being implemented to ensure that the issue will not occur again.

• State whether the staff and/or organizational component involved in the identified issue(s) will work on the proposed contract. If so, provide information to assure the agency that the issue will not be repeated.

• Identify the relationship (or lack thereof) between the product/services involved in the issue and the type of product/services proposed for this contract.

• State whether the issue will affect your financial or organizational ability to perform under the proposed contract.

• Provide copies of relevant documents or any other information that would assist Upstate in its evaluation.

It is imperative the person completing the questionnaires and forms be knowledgeable about the proposing vendor’s business and operations, as an owner or officer, he or she must attest to the questionnaires’ and forms’ information.

Note: Page one of the ST-220-CA form refers to form ST-220-TD. The ST-220-TD form must be submitted by the vendor directly to the New York State Department of Taxation and Finance. The ST-220-TD is available on-line from the following web site:

http://www.tax.ny.gov/pdf/current_forms/st/st220td_fill_in.pdf

Checklist for signatures, notarization, and attachments required for this packet:

Page 11 Signature – Vendor Responsibility

Pages 13-16 Signature – NYS SFL139, Public Officers Law, EO 16, EO177 section

Page 17 Workers’ Compensation and Disability Benefits forms

Page 18 (page 1 of ST-220-CA) Complete and sign as required – NY State Department of Taxation and Finance ST-220-CA section

Page 19 (page 2 of ST-220-CA) Notary signature - ST-220-CA Attachments for additional information (as needed)

ALL INFORMATION REQUESTED MUST BE PROVIDED AND ALL QUESTIONS MUST BE ANSWERED.

If you have any questions regarding this packet, contact Emily Brown at 315-464-8922 or e-mail brownemi@upstate.edu Send completed packet to:

Attn: Emily Brown Contracts & Campus Purchasing SUNY Upstate Medical University 750 East Adams Street Syracuse, New York 13210 Revised March 2020 http://www.tax.ny.gov/pdf/current_forms/st/st220td_fill_in.pdf mailto:tackleyw@upstate.edu

AC 3290-S (Rev. 03/2022) NYS Vendor ID: 000000000

NEW YORK STATE

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

You have selected the For-Profit Non-Construction questionnaire which may be printed and completed in this format or, for your convenience, may be completed online using the New York State VendRep System.

COMPLETION & CERTIFICATION

The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or owner’s official representative authorized to legally bind the Reporting Entity must certify the truth of the questionnaire answers.

NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID)

The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk at ITServiceDesk@osc.state.ny.us or call 866-370-4672.

DEFINITIONS

All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at https://www.osc.state.ny.us/files/vendors/2017-11/vendor-questionnaire-definitions.pdf. These terms may not have their ordinary, common or traditional meanings. Each vendor must read the respective definitions for any and all underlined terms. By submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility Definitions List" existing at the time of certification.

RESPONSES

Every question must be answered fully. Each response must provide all relevant information to appropriately explain the answer. If you have concerns as to the legal requirements behind your answers, please seek clarification from your counsel. However, information regarding a determination or finding made in error which was subsequently corrected or overturned, and/or was withdrawn by the issuing government entity is not required to be identified. Individuals and Sole Proprietors may use a Social Security Number but are encouraged to obtain and use a federal Employer Identification Number (EIN).

REPORTING ENTITY

Each vendor must indicate if the questionnaire is filed on behalf of the entire Legal Business Entity or an Organizational Unit within or operating under the authority of the Legal Business Entity and having the same EIN. Generally, the Organizational Unit option may be appropriate for a vendor that meets the definition of “Reporting Entity” but due to the size and complexity of the Legal Business Entity, is best able to provide the required information for the Organizational Unit, while providing more limited information for other parts of the Legal Business Entity and Associated Entities.

ASSOCIATED ENTITY

An Associated Entity is one that owns or controls the Reporting Entity, or any entity owned or controlled by the Reporting Entity.

However, the term Associated Entity does not include “sibling organizations” (i.e., entities owned or controlled by a parent company that owns or controls the Reporting Entity), unless such sibling entity has a direct relationship with or impact on the Reporting Entity. Please refer to the Definitions List for the complete definition.

STRUCTURE OF THE QUESTIONNAIRE

The questionnaire is organized into eleven sections. Section I is to be completed for the Legal Business Entity. Section II requires the vendor to specify the Reporting Entity for the questionnaire. Section III refers to the individuals of the Reporting Entity, while Sections IV-VIII require information about the Reporting Entity. Section IX pertains to any Associated Entities, with one question about their Officials/Owners. Section X relates to disclosure under the Freedom of Information Law (FOIL). Section XI requires an authorized contact for the questionnaire information.

http://www.osc.state.ny.us/vendrep/ mailto:ITServiceDesk@osc.state.ny.us https://www.osc.state.ny.us/files/vendors/2017-11/vendor-questionnaire-definitions.pdf

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

I. LEGAL BUSINESS ENTITY INFORMATION

Legal Business Entity Name0F* EIN

Address of the Principal Place of Business (street, city, state, zip code) New York State Vendor Identification Number

Telephone Ext.

Fax

Email Website

Additional Legal Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN used in the last five (5) years and the status (active or inactive).

Type Name EIN Status

1.0 Legal Business Entity Type – Check appropriate box and provide additional information:

Corporation (including PC) Date of Incorporation

Limited Liability Company (LLC or PLLC) Date of Organization

Partnership (including LLP, LP or General) Date of Registration or Establishment

Sole Proprietor How many years in business?

Other Date Established

If Other, explain:

1.1 Was the Legal Business Entity formed or incorporated in New York State? Yes No

If ‘No,’ indicate jurisdiction where Legal Business Entity was formed or incorporated and attach a Certificate of Good Standing from the applicable jurisdiction or provide an explanation if a Certificate of Good Standing is not available.

United States State

Other Country

Explain, if not available:

1.2 Is the Legal Business Entity publicly traded? Yes No

If “Yes,” provide CIK Code or Ticker Symbol

1.3 Does the Legal Business Entity have a DUNS Number? Yes No

If “Yes,” Enter DUNS Number

*All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” which can be found at

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

I. LEGAL BUSINESS ENTITY INFORMATION

1.4 If the Legal Business Entity’s Principal Place of Business is not in New York State, does the Legal Business Entity maintain an office in New York State?

(Select “N/A,” if Principal Place of Business is in New York State.)

Yes No N/A

If “Yes,” provide the address and telephone number for one office located in New York State.

1.5 Is the Legal Business Entity a New York State certified Minority-Owned Business Enterprise (MBE), Women-Owned Business Enterprise (WBE), Service-Disabled Veteran-Owned Business (SDVOB), New York State Small Business (SB) or a federally certified Disadvantaged Business Enterprise (DBE)?

If “Yes,” check all that apply:

New York State certified Minority-Owned Business Enterprise (MBE) New York State certified Women-Owned Business Enterprise (WBE) New York State certified Service-Disabled Veteran-Owned Business (SDVOB) New York State Small Business (SB) Federally certified Disadvantaged Business Enterprise (DBE)

Yes No

1.6 Identify Officials and Principal Owners of the Reporting Entity, if applicable. For each person, include name, title, date of birth, and percentage of ownership. For each Business Entity that is a Principal Owner, include name, address, EIN, and percentage ownership. Identify all Business Entities owning 25% or more of the Reporting Entity and include name, address, EIN and percentage of ownership. Attach additional pages if necessary. If applicable, reference to relevant SEC filing(s) containing the required information is optional. Each Business Entity identified as a Principal Owner must also submit a vendor responsibility questionnaire.

If there is no person or Business Entity that owns 25% or more of the Reporting Entity (or 10% or more if the Reporting Entity is publicly traded), check here.

Name of Officials and Principal Owners (for each person, please include a middle initial)

Title Date of Birth Percentage Ownership (Enter 0% if not applicable)

Name of each Business Entity owning 25% or more of Reporting Entity

Address EIN Percentage Ownership

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

II. REPORTING ENTITY INFORMATION

2.0 The Reporting Entity for this questionnaire is:

Note: Select only one.

Legal Business Entity Note: If selecting this option, “Reporting Entity” refers to the entire Legal Business Entity for the remainder of the questionnaire. (SKIP THE REMAINDER OF SECTION II AND PROCEED WITH SECTION III.)

Organizational Unit within and operating under the authority of the Legal Business Entity

SEE DEFINITIONS OF “REPORTING ENTITY” AND “ORGANIZATIONAL UNIT” FOR ADDITIONAL

INFORMATION ON CRITERIA TO QUALIFY FOR THIS SELECTION.

Note: If selecting this option, “Reporting Entity” refers to the Organizational Unit within the Legal Business Entity for the remainder of the questionnaire. (COMPLETE THE REMAINDER OF SECTION II AND ALL REMAINING

SECTIONS OF THIS QUESTIONNAIRE.)

IDENTIFYING INFORMATION

a) Reporting Entity Name

Address of the Primary Place of Business (street, city, state, zip code) Telephone ext.

b) Describe the relationship of the Reporting Entity to the Legal Business Entity

c) Attach an organizational chart

d) Does the Reporting Entity have a DUNS Number? Yes No

If “Yes,” enter DUNS Number

e) Identify the designated manager(s) responsible for the business of the Reporting Entity.

For each person, include name and title. Attach additional pages if necessary.

Name Title

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

INSTRUCTIONS FOR SECTIONS III THROUGH VII

For each “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). For each “Other,” provide an explanation which provides the basis for not definitively responding “Yes” or “No.” Provide the explanation at the end of the section or attach additional sheets with numbered responses, including the Reporting Entity name at the top of any attached pages.

III. LEADERSHIP INTEGRITY

Within the past five (5) years, has any current or former reporting entity official or any individual currently or formerly having the authority to sign, execute or approve bids, proposals, contracts or supporting documentation on behalf of the reporting entity with any government entity been:

3.0 Sanctioned relative to any business or professional permit and/or license? Yes No Other

3.1 Suspended, debarred, or disqualified from any government contracting process? Yes No Other

3.2 The subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation for any business-related conduct?

Yes No Other

3.3 Charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a judgment for:

a) Any business-related activity; or

b) Any crime, whether or not business-related, the underlying conduct of which was related to truthfulness?

Yes No Other

For each “Yes” or “Other” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

IV. INTEGRITY – CONTRACT BIDDING

Within the past five (5) years, has the reporting entity:

4.0 Been suspended or debarred from any government contracting process or been disqualified on any government procurement, permit, license, concession, franchise or lease, including, but not limited to, debarment for a violation of New York State Workers’ Compensation or Prevailing Wage laws or New York State Procurement Lobbying Law?

Yes No

4.1 Been subject to a denial or revocation of a government prequalification? Yes No

4.2 Been denied a contract award or had a bid rejected based upon a non-responsibility finding by a government entity?

Yes No

4.3 Had a bid rejected on a government contract for failure to make good faith efforts on any Minority- Owned Business Enterprise, Women-Owned Business Enterprise, Service-Disabled Veteran-Owned Business or Disadvantaged Business Enterprise goal or statutory affirmative action requirements on a previously held contract?

Yes No

4.4 Agreed to a voluntary exclusion from bidding/contracting with a government entity? Yes No

4.5 Initiated a request to withdraw a bid submitted to a government entity in lieu of responding to an information request or subsequent to a formal request to appear before the government entity?

Yes No

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

V. INTEGRITY – CONTRACT AWARD

Within the past five (5) years, has the reporting entity:

5.0 Been suspended, cancelled or terminated for cause on any government contract including, but not limited to, a non-responsibility finding?

Yes No

5.1 Been subject to an administrative proceeding or civil action seeking specific performance or restitution in connection with any government contract?

Yes No

5.2 Entered into a formal monitoring agreement as a condition of a contract award from a government entity? Yes No

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

VI. CERTIFICATIONS/LICENSES

Within the past five (5) years, has the reporting entity:

6.0 Had a revocation, suspension or disbarment of any business or professional permit and/or license? Yes No

6.1 Had a denial, decertification, revocation or forfeiture of New York State certification of Minority-Owned Business Enterprise, Women-Owned Business Enterprise, Service-Disabled Veteran-Owned Business or federal certification of Disadvantaged Business Enterprise status for other than a change of ownership?

Yes No

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered responses if necessary:

VII. LEGAL PROCEEDINGS

Within the past five (5) years, has the reporting entity:

7.0 Been the subject of an investigation, whether open or closed, by any government entity for a civil or criminal violation?

Yes No

7.1 Been the subject of an indictment, grant of immunity, judgment or conviction (including entering into a plea bargain) for conduct constituting a crime?

Yes No

7.2 Received any OSHA citation and Notification of Penalty containing a violation classified as serious or willful?

Yes No

7.3 Had a government entity find a willful prevailing wage or supplemental payment violation or any other willful violation of New York State Labor Law?

Yes No

7.4 Entered into a consent order with the New York State Department of Environmental Conservation, or received an enforcement determination by any government entity involving a violation of federal, state or local environmental laws?

Yes No

7.5 Other than previously disclosed:

a) Been subject to fines or penalties imposed by government entities which in the aggregate total

$25,000 or more; or

b) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any government entity?

For each “Yes,” provide an explanation for the response and attach additional sheets with numbered response if necessary:

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

VIII. FINANCIAL AND ORGANIZATIONAL CAPACITY

8.0 Within the past five (5) years, has the Reporting Entity received any formal unsatisfactory performance assessment(s) from any government entity on any contract?

Yes No

If “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.1 Within the past five (5) years, has the Reporting Entity had any liquidated damages assessed over $25,000 for any reason, including failure to meet Minority-Owned Business Enterprise, Women-Owned Business Enterprise, Service-Disabled Veteran-Owned Business, or Disadvantaged Business Enterprise goals?

Yes No

If “Yes,” provide an explanation of the issue(s), relevant dates, contracting party involved, the amount assessed and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.2 Within the past five (5) years, have any liens, claims or judgments (not including UCC filings) over $25,000 been filed against the Reporting Entity which remain undischarged?

Yes No

If “Yes,” provide an explanation of the issue(s), relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s), the current status of the issue(s), and the balance of the lien or judgment not yet paid. Provide answer below or attach additional sheets with numbered responses.

8.3 In the last seven (7) years, has the Reporting Entity initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

Yes No

If “Yes,” provide the bankruptcy chapter number, the court name and the docket number. Indicate the current status of the proceedings as “Initiated,” “Pending” or “Closed.” Provide answer below or attach additional sheets with numbered responses.

8.4 During the past three (3) years, has the Reporting Entity failed to file or pay any tax returns required by federal, state or local tax laws?

Yes No

If “Yes,” provide the taxing jurisdiction, the type of tax, the liability year(s), the tax liability amount the Reporting Entity failed to file/pay and the current status of the tax liability. Provide answer below or attach additional sheets with numbered responses.

8.5 During the past three (3) years, has the Reporting Entity failed to file or pay any New York State unemployment insurance returns?

Yes No

If “Yes,” provide the years the Reporting Entity failed to file/pay the insurance, explain the situation and any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

8.6 During the past three (3) years, has the Reporting Entity had any government audit(s) completed? Yes No

a) If “Yes,” did any audit of the Reporting Entity identify any reported significant deficiencies in internal control, fraud, illegal acts, significant violations of provisions of contract or grant agreements, significant abuse or any material disallowance?

Yes No

If “Yes” to 8.6 a), provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

IX. ASSOCIATED ENTITIES

This section pertains to any entity(ies) that either controls or is controlled by the reporting entity.

(See definition of “associated entity” for additional information to complete this section.)

9.0 Does the Reporting Entity have any Associated Entities?

Note: All questions in this section must be answered if the Reporting Entity is either:

− An Organizational Unit; or − The entire Legal Business Entity which controls, or is controlled by, any other entity(ies).

If “No,” SKIP THE REMAINDER OF SECTION IX AND PROCEED WITH SECTION X.

If “Yes,” provide the name, address and EIN of each Associated Entity and its relationship to the Reporting Entity.

Yes No

9.1 Within the past five (5) years, has any Associated Entity Official or Principal Owner been charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a judgment for:

a) Any business-related activity; or

b) Any crime, whether or not business-related, the underlying conduct of which was related to truthfulness?

Yes No

If “Yes,” provide an explanation of the issue(s), the individual involved, their title and role in the Associated Entity, identify the Associated Entity’s name(s), EIN(s), primary business activity, the individual’s relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s).

9.2 Does any Associated Entity have any currently undischarged federal, New York State, New York City or New York local government liens or judgments (not including UCC filings) over $50,000?

Yes No

If “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the Lien holder or Claimant’s name(s), the amount of the lien(s) and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

9.3 Within the past five (5) years, has any Associated Entity:

a) Been disqualified, suspended or debarred from any federal, New York State, New York City or other New York local government contracting process?

Yes No

b) Been denied a contract award or had a bid rejected based upon a non-responsibility finding by any federal, New York State, New York City, or New York local government entity?

Yes No

c) Been suspended, cancelled or terminated for cause (including for non-responsibility) on any federal, New York State, New York City or New York local government contract?

Yes No

d) Been the subject of an investigation, whether open or closed, by any federal, New York State, New York City, or New York local government entity for a civil or criminal violation with a penalty in excess of $500,000?

Yes No

e) Been the subject of an indictment, grant of immunity, judgment, or conviction (including entering into a plea bargain) for conduct constituting a crime?

Yes No

f) Been convicted of a criminal offense pursuant to any administrative and/or regulatory action taken by any federal, New York State, New York City, or New York local government entity?

Yes No

g) Initiated or been the subject of any bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

IX. ASSOCIATED ENTITIES

This section pertains to any entity(ies) that either controls or is controlled by the reporting entity.

(See definition of “associated entity” for additional information to complete this section.)

For each “Yes,” provide an explanation of the issue(s), identify the Associated Entity’s name(s), EIN(s), primary business activity, relationship to the Reporting Entity, relevant dates, the government entity involved, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

X. FREEDOM OF INFORMATION LAW (FOIL)

10. Indicate whether any information supplied herein is believed to be exempt from disclosure under the Freedom of Information Law (FOIL).

Note: A determination of whether such information is exempt from FOIL will be made at the time of any request for disclosure under FOIL.

Yes No

If “Yes,” indicate the question number(s) and explain the basis for the claim.

XI. AUTHORIZED CONTACT FOR THIS QUESTIONNAIRE

Name Telephone Fax ext.

Title Email

VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT BUSINESS ENTITY

Certification

The undersigned: (1) recognizes that this questionnaire is submitted for the express purpose of assisting New York State government entities (including the Office of the State Comptroller (OSC)) in making responsibility determinations regarding award or approval of a contract or subcontract and that such government entities will rely on information disclosed in the questionnaire in making responsibility determinations; (2) acknowledges that the New York State government entities and OSC may, in their discretion, by means which they may choose, verify the truth and accuracy of all statements made herein; and (3) acknowledges that intentional submission of false or misleading information may result in criminal penalties under State and/or federal law, as well as a finding of non-responsibility, contract suspension or contract termination.

It being acknowledged and agreed that all responses included in this questionnaire are to the knowledge, information and belief of the Business Entity, the undersigned certifies under penalties of perjury that they:

The undersigned certifies that he/she:

• are knowledgeable about the submitting Business Entity's business and operations;

• have legal authority to bind the Business Entity;

• have read and understand all of the questions contained in the questionnaire, including all definitions;

• have not altered the content of the questionnaire in any manner;

• have reviewed and/or supplied full and complete responses to each question;

• have provided true, accurate and complete responses, including all attachments, if applicable;

• understand that New York State government entities will rely on the information disclosed in the questionnaire when entering into a contract with the Business Entity; and

• are under an obligation to update the information provided herein to include any material changes to the Business Entity's responses at the time of bid/proposal submission through the contract award notification, and may be required to update the information at the request of the New York State government entities or OSC prior to the award and/or approval of a contract, or during the term of the contract.

Signature of Owner/Official

Printed Name of Signatory

Title

Name of Business

Address

City, State, Zip

Date

Revised 06/06/2022

NEW YORK SFL §139, PUBLIC OFFICERS LAW & CERTIFICATIONS VENDOR PACKET

Contents:

Introduction, Directions, and Contact Information

New York State Finance Law 139 (SFL139) form

Public Officers Law form EO 177 Certification (Non-Discrimination) EO 16 Certification (Conducting Business in Russia)

Introduction:

All procurements by SUNY Upstate Medical University (Upstate) valued at $15,000 or greater, are subject to New York

State’s State Finance Law Sections §§139-j and 139-k, effective January 1, 2006.

Pursuant to SFL §139, all contacts and inquiries (oral, written, or electronic communications) with Upstate, occurring during procurement, must be made with a designated Point of Contact.

Moreover, SFL §139 requires Upstate to obtain certain affirmations and certifications from vendors. The attached New

York State Finance Law §139 Vendor Form provides a means for SUNY Upstate to obtain those affirmations and certifications. For your review, New York State Finance Law §139 can be found at the following web site:

http://ogs.ny.gov/aboutogs/regulations/advisoryCouncil/StatutoryReferences.html.

Directions:

1. The SUNY Upstate Medical University New York State Finance Law §139 vendor form consists of one (1) page.

2. You must answer all questions contained within the form.

3. Where a response requires additional information, attach a written response that adequately details the requested information. Please note on each response the question number.

4. The completed form and any attached responses will become a part of SUNY Upstate Medical University’s procurement record.

5. If electronic, the form is a fillable document using Microsoft Word or Adobe (for PDFs).

It is imperative the person completing the form be knowledgeable about the vendor’s business and operations. As an owner or officer, he or she will certify the form’s information.

To expedite the receipt of the completed and signed form scan the completed document and e-mail it to or you may fax it to (315) 464-4599, Attn: .

The original must be sent to the following address:

SUNY Upstate Medical University

Contracts & Campus Purchasing

Attn:

750 East Adams Street

Syracuse, New York 13210

Contact Information:

If you have any questions or concerns regarding the form, please contact the procurement officer noted above at (315) 464-8922 or via their e-mail address.

Revised October 2011

STATE FINANCE LAW §139

Contractor Disclosure of Prior Non-Responsibility Determinations and Contract Termination Provision This form shall be completed and submitted in accordance with New York State, State Finance Law (SFL) §§139-j and 139-k. Failure to complete and submit this form shall result in a determination of non-responsiveness and disqualification of the bid, proposal or offer. You agree to update this information as changes occur or as requested. New York State’s State Finance Laws can be found at:

http://ogs.ny.gov/aboutogs/regulations/advisoryCouncil/StatutoryReferences.html

Upstate Medical University reserves the right to terminate this contract in the event it is found that the certification filed by the Offerer in accordance with

New York State Finance Law §139-k was intentionally false or intentionally incomplete. Upon such finding, the Upstate Medical University may exercise its termination right by providing written notification to the Offerer in accordance with the written notification terms of this contract.

Name of Contractor: Fed. ID#

Address:

Name of Person Submitting this Form:

Title of Person Submitting this Form:

Has any Governmental Entity made a finding of non-responsibility regarding the individual or entity seeking to enter into the Procurement Contract in the previous four years? (Please check): No Yes

If yes, was the basis for the finding of non-responsibility was the basis for the finding of non-responsibility due to a violation of State Finance Law §139-j?

(Please check): No Yes

If yes, was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Governmental Entity?

(Please check): No Yes

If yes to any on the above, please provide details below regarding the finding of non-responsibility. Attach additional pages as necessary.

Covered agency or authority:

Year of finding of non-responsibility:

Basis of finding of non-responsibility:

Has any Governmental Entity or other governmental agency terminated or withheld a Procurement Contract with the above-named individual or entity due to the intentional provision of false or incomplete information? (Please check):

No Yes

If yes, please provide details below. Attach additional pages as necessary.

Governmental entity or agency:

Date of termination or withholding of contract:

Basis of termination or withholding:

All contacts and/or inquiries regarding this procurement, be they oral, written, or electronic commencing with the earliest written notice, advertisement, or solicitation and ending with the final contract award, approved by SUNY Upstate Medical University and, where applicable, Office of the State Comptroller shall only be directed to the following persons:

Phone: (315) 464-8922 E-mail:

Fax: (315) 464-4599

Contracts & Campus Purchasing

SUNY Upstate Medical University

750 East Adams Street

Syracuse, NY 13210

Offerer affirms that it understands and agrees to comply with the procedures of the Government Entity relative to permissible Contacts as required by State

Finance Law §139-j (3) and §139-j (6) (b). Offerer certifies that all information provided to the Agency is complete, true, and accurate with regard to prior non-responsibility determinations within the past five years based on (i) impermissible contacts or other violations of SFL §139-j, or (ii) the intentional provision of false or intentionally incomplete information.

Signature: _________________________

Name: ____________________________ Title: ___________________________ Date: _____________________ http://ogs.ny.gov/aboutogs/regulations/advisoryCouncil/StatutoryReferences.html

Revised October 2011

Public Officers Law - Form

Introduction:

The conflict of interest and code of ethics provisions of New York State Public Officers Law §§73 & 74 shall apply to all purchasing activities of SUNY Upstate Medical University and University Hospital at Community General (collectively Upstate). Upstate is required to inquire if any member of a business entity is an officer or employee of the State of New York or of a public benefit corporation of the State of

New York.

Directions:

1. The SUNY Upstate Medical University Public Officers Law form consists of one (1) page.

2. Please complete all required information as the completed form will become a part of SUNY Upstate Medical University’s procurement record.

3. If electronic, the form is a fillable document using Microsoft Word.

or

It is imperative the person completing the form be knowledgeable about the vendor’s business and operations. As an owner or officer, he or she will certify the form’s information.

To expedite the receipt of the completed and signed form scan the completed document and e-mail it to you may fax it to (315) 464-8922, Attn: .

The original must be sent to the following address:

SUNY Upstate Medical University

Contracts & Campus Purchasing

Attn:

750 East Adams Street

Syracuse, New York 13210

Name of Contractor: Fed. ID#

Address:

Name of Person Submitting this Form:

Title of Person Submitting this Form:

Question:

Indicate if you or any officer of your organization, or any party owning or controlling more than ten (10) percent of your stock if you are a corporation, or any member if you are a firm or association is an officer or employee of the State of New York or of a public benefit corporation of the State of New York.

Yes No

Signature: ________________________________

Printed Name: Date: __________________

Contact Information:

If you have any questions or concerns regarding the form, please contact the procurement officer at (315) 464-5720 or via their e-mail address noted above.

EO 177 Certification

The New York State Human Rights Law, Article 15 of the Executive Law, prohibits discrimination and harassment based on age, race, creed, color, national origin, sex, pregnancy or pregnancy-related conditions, sexual orientation, gender identity, disability, marital status, familial status, domestic violence victim status, prior arrest or conviction record, military status or predisposing genetic characteristics.

The Human Rights Law may also require reasonable accommodation for persons with disabilities and pregnancy-related conditions. A reasonable accommodation is an adjustment to a job or work environment that enables a person with a disability to perform the essential functions of a job in a reasonable manner. The Human Rights Law may also require reasonable accommodation in employment on the basis of Sabbath observance or religious practices.

Generally, the Human Rights Law applies to:

• all employers of four or more people, employment agencies, labor organizations and apprenticeship training programs in all instances of discrimination or harassment;

• employers with fewer than four employees in all cases involving sexual harassment; and,

• any employer of domestic workers in cases involving sexual harassment or harassment based on gender, race, religion or national origin.

In accordance with Executive Order No. 177, the Bidder hereby certifies that it does not have institutional policies or practices that fail to address the harassment and discrimination of individuals on the basis of their age, race, creed, color, national origin, sex, sexual orientation, gender identity, disability, marital status, military status, or other protected status under the Human Rights Law.

Executive Order No. 177 and this certification do not affect institutional policies or practices that are protected by existing law, including but not limited to the First Amendment of the United States Constitution, Article 1, Section 3 of the New York State Constitution, and Section 296(11) of the New York State Human Rights Law.

Contractor:

Signature:

Name:

Title:

Date:

___________________ ____, 20____

Executive Order No. 16 provides that “all Affected State Entities are directed to refrain from entering into any new contract or renewing any existing contract with an entity conducting business operations in Russia.” The complete text of Executive Order No. 16 can be found here.

The Executive Order remains in effect while sanctions imposed by the federal government are in effect.

Accordingly, vendors who may be excluded from award because of current business operations in Russia are nevertheless encouraged to respond to solicitations to preserve their contracting opportunities in case the sanctions are lifted during a solicitation or even after award in the case of some solicitations.

As defined in Executive Order No. 16, an “entity conducting business operations in Russia” means an institution or company, wherever located, conducting any commercial activity in Russia or transacting business with the Russian Government or with commercial entities headquartered in Russia or with their principal place of business in Russia in the form of contracting, sales, purchasing, investment, or any business partnership.

Is Vendor an entity conducting business operations in Russia, as defined above? Please answer by checking one of the following boxes:

1. No, Vendor does not conduct business operations in Russia within the meaning of Executive Order No. 16.

2.a. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but has taken steps to wind down business operations in Russia or is in the process of winding down business operations in Russia. (Please provide a detailed description of the wind down process and a schedule for completion.)

2.b. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16 but only to the extent necessary to provide vital health and safety services within Russia or to comply with federal law, regulations, executive orders, or directives. (Please provide a detailed description of the services being provided or the relevant laws, regulations, etc.)

3. Yes, Vendor conducts business operations in Russia within the meaning of Executive Order No. 16.

The undersigned certifies under penalties of perjury that they are knowledgeable about the Vendor’s business and operations and that the answer provided herein is true to the best of their knowledge and belief.

Vendor Name:

(legal entity)

By:

(signature)

Name:

Title:

Date:

Certification Under Executive Order No. 16 Prohibiting State Agencies and Authorities from Contracting with

Businesses Conducting Business in Russia https://www.governor.ny.gov/executive-order/no-16-prohibiting-state-agencies-and-authorities-contracting-businesses-conducting

WORKERS’ COMPENSATION AND DISABILITY BENEFITS COMPLIANCE SECTION

Compliance with Workers’ Compensation and Disability Benefits Coverage Requirements

Sections 57 and 220 of the New York State Workers’ Compensation Law (WCL) provide Procuring Agencies shall not enter into any contracts (new or renewal) or issue Purchase Orders unless proof of workers’ compensation and disability benefits insurance coverage is produced. Prior to entering into a contract with SUNY Upstate Medical University (Upstate), vendors are required to verify for Upstate, on forms authorized by the New York State Workers’ Compensation Board, the fact that they are properly insured or are otherwise in compliance with the insurance provisions of the WCL. The forms used to show compliance with the WCL are described below. An ACORD form is not acceptable proof of workers’ compensation coverage or disability benefits insurance coverage.

For bids or proposals: Failure to provide verification of either of these types of insurance coverage by the time the winning Offeror is selected and the contract is ready to be executed will be grounds for disqualification of an otherwise successful bid or proposal.

For Purchase Orders: Purchase Orders will not be issued without verification of either of these types of insurance coverage.

Any questions relating to either workers’ compensation or disability benefits coverage should be directed to the State of New York Workers’ Compensation Board, Bureau of Compliance at (518)486-6307. You may also find useful information at the following website:

http://www.wcb.ny.gov/ .

Proof of Compliance with Workers’ Compensation Coverage Requirements In order to provide proof of compliance with the requirements of the Workers’ Compensation Law pertaining to workers’ compensation coverage, a contractor shall:

1. Be legally exempt from obtaining Workers’ Compensation insurance coverage; or

2. Obtain such coverage from an insurance carrier; or

3. Be a Workers’ Compensation Board-approved self-insured employer or participate in an authorized self-insurance plan.

A Contractor seeking to enter into a contract with the State of New York shall provide one of the following forms to Upstate at the time of bid submission or shortly after the opening of bids:

1. Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain out of State Entities, that New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website ( http://www.wcb.ny.gov/); (Reference applicable IFB/RFP and Group #s on the form.)

2. Certificate of Workers’ Compensation Insurance:

a. Form C-105.2 (9/07) if coverage is provided by the contractor’s insurance carrier, contractor must request its carrier to send this form to SUNY Upstate, or

b. Form U-26.3 if coverage is provided by the State Insurance Fund, contractor must request that the State Insurance Fund send this form SUNY Upstate.

3. Form SI-12, Certificate of Workers’ Compensation Self-Insurance available from the New York State Workers’ Compensation

Board’s Self-Insurance Office.

4. Form GSI-105.2, Certificate of Participation in Workers’ Compensation Group Self-Insurance available from the contractor’s

Group Self- Insurance Administrator.

Proof of Compliance with Disability Benefits Coverage Requirements In order to provide proof of compliance with the requirements of the Workers’ Compensation Law pertaining to disability benefits, a contractor shall:

1. Be legally exempt from obtaining disability benefits coverage; or

2. Obtain such coverage from an insurance carrier; or

3. Be a Board-approved self-insured employer.

A Contractor seeking to enter into a contract with the State of New York shall provide one of the following forms to Upstate at the time of bid submission or shortly after the opening of bids:

1. Form CE-200, Certificate of Attestation for New York Entities With No Employees and Certain Out of State Entities, that New York State Workers’ Compensation and/or Disability Benefits Insurance Coverage is Not Required, which is available on the Workers’ Compensation Board’s website (http://www.wcb.ny.gov/); (Reference applicable IFB/RFP and Group #s on the form.)

2. Form DB-120.1, Certificate of Disability Benefits Insurance. Contractor must request its business insurance carrier to send this form to SUNY Upstate; or

3. Form DB-155, Certificate of Disability Benefits Self-Insurance. The Contractor must call the Board’s Self-Insurance Office at 518-402- 0247 to obtain this form.

ALL OF THE ABOVE REFERENCED FORMS, EXCEPT CE-200, SI-12 & DB-155 MUST NAME: SUNY Upstate Medical University, Contracts & Campus Purchasing Dept., 750 E. Adams Street, Syracuse, NY 13210 as the Entity Requesting Proof of Coverage (Entity being listed as the Certificate Holder).

END OF WORKERS’ COMPENSATION AND DISABILITY BENEFITS COMPLIANCE SECTION

http://www.wcb.ny.gov/ http://www.wcb.ny.gov/ http://www.wcb.ny.gov/

New York State Department of Taxation and Finance

Contractor Certification to Covered Agency (Pursuant to Section 5-a of the Tax Law, as amended, effective April 26, 2006)

ST-220-CA

(12/11)

Contractor name

Contractor’s principal place of business City State ZIP code

Contractor’s mailing address (if different than above)

Contractor’s federal employer identification number (EIN) Contractor’s sales tax ID number (if different from contractor’s EIN)

Contractor’s telephone number Covered agency name

Covered agency address

of the above‑named contractor, that I am authorized to make this certification on behalf of such contractor, and I further certify that:

(Mark an X in only one box)

G The contractor has filed Form ST-220-TD with the Department of Taxation and Finance in connection with this contract and, to the best of contractor’s knowledge, the information provided on the Form ST-220-TD, is correct and complete.

G The contractor has previously filed Form ST-220-TD with the Tax Department in connection with (insert contract number or description) and, to the best of the contractor’s knowledge, the information provided on that previously filed Form ST-220-TD, is correct and complete as of the current date, and thus the contractor is not required to file a new Form ST-220-TD at this time.

Sworn to this day of , 20

(sign before a notary public) (title)

For covered agency use only

Contract number or description

Estimated contract value over the full term of contract (but not including renewals)

Covered agency telephone number

For information, consult Publication 223, Questions and Answers Concerning Tax Law Section 5-a (see Need Help? on back).

Instructions

General information Tax Law section 5-a was amended, effective April 26, 2006. On or after that date, in all cases where a contract is subject to Tax Law section 5-a, a contractor must file (1) Form ST-220-CA, Contractor Certification to Covered Agency, with a covered agency, and

(2) Form ST-220-TD with the Tax Department before a contract may take effect. The circumstances when a contract is subject to section 5-a are listed in Publication 223, Q&A 3. See Need help?

for more information on how to obtain this publication. In addition, a contractor must file a new Form ST-220-CA with a covered agency before an existing contract with such agency may be renewed.

Note: Form ST-220-CA must be signed by a person authorized to make the certification on behalf of the contractor, and the acknowledgement on page 2 of this form must be completed before a notary public.

When to complete this form As set forth in Publication 223, a contract is subject to section 5-a, and you must make the required certification(s), if:

i. The procuring entity is a covered agency within the meaning of the statute (see Publication…