FORM C

Disclosure and Certification with respect to State Finance Law §§139-j and 139-k         

 

Procurement Description/ID No._______________________

 

1.         Has a Governmental Entity, as defined in State Finance Law §139-j(1)(a), made a determination of non-responsibility with respect to the Offerer within the previous four years where such finding was due to a violation of State Finance Law §139-j or the intentional provision of false or incomplete information with respect to previous determinations of non-responsibility?

 

No ___

Yes ___

 

If yes,  provide the following details:

Governmental Entity which made the finding:

Date of finding:

Basis of finding:

 

2.         Has a Governmental Entity terminated or withheld a procurement contract with the Offer because of violations of State Finance Law §139-j or the intentional provision of false or incomplete information with respect to previous determinations of non-responsibility?

 

No ___

Yes ___

 

If yes, identify the following:

Governmental Entity which terminated the contract:

Date of contract termination or withholding:

Identify the related procurement contract:

 

Offerer CERTIFIES that all information provided by Offerer with respect to its compliance with State Finance Law §§139-j and 139-k is complete, true and accurate.

 

                                                                                                           

Name of Offerer:

 

Address:

 

Signature of Person Submitting Form:    _________________________________                                         

                                                                        Name:

                                                                        Title:

                                                                        Date: