Specifications

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6. If yes, please provide details below.
Governmental Entity: ______________________________________________
Date of Termination or Withholding of Contract: ______________________________________
Basis of Termination or Withholding: ____________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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(Add additional pages as necessary)
Offerer certifies that all information provided to the Governmental Entity with respect to
State Finance Law §139-k is complete, true and accurate.
By: Date:
Signature