Specifications

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Offerer Disclosure of Prior Non-Responsibility Determinations
Name of Individual or Entity Seeking to Enter into the Procurement Contract:
__________________________________________________________________________
Address: __________________________________________________________________
__________________________________________________________________________
Name and Title of Person Submitting this Form:
__________________________________________________________________________
__________________________________________________________________________
Contract Procurement Number: _____________________
Date:___________________________
1. 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 circle):
No ___ Yes ___
If yes, please answer the next questions:
2. Was the basis for the finding of non-responsibility due to a violation of State Finance Law
§139-j (Please circle):
No ___ Yes ___
3. Was the basis for the finding of non-responsibility due to the intentional provision of false or
incomplete information to a Governmental Entity? (Please circle):
No ___ Yes ___
4. If you answered yes to any of the above questions, please provide details regarding the finding
of non-responsibility below.
Governmental Entity: ___________________________________________________________
Date of Finding of Non-responsibility: ______________________________________________
Basis of Finding of Non-Responsibility: _____________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(Add additional pages as necessary)
5. 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 circle):
No ___ Yes ___