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Office of the Illinois State Treasurer

Michael W. Frerichs

Request for Proposals External Investment Advisor

Addendum 2

October 6, 2015

The Office of the Illinois State Treasurer published a Request for Proposals External Investment

Advisor on September 15, 2015 (“RFP”). The Appendices for the RFP are attached hereto.

All other terms and conditions of the RFP remain unchanged.

Please e-mail Chief Procurement Officer Jim Underwood at junderwood@illinoistreasurer.gov

with questions regarding this addendum or the RFP.

Appendix A

LLINOIS STATE TREASURER CERTIFICATIONS

______________________________________________ (“CONTRACTOR”) makes the following

certifications:

1.0 ANTI-BRIBERY.

CONTRACTOR certifies that it is not barred from being awarded a contract or subcontract

under Section 50-5 of the Illinois Procurement Code (30 ILCS 500/50-5). Section 50-5 prohibits a

contractor from entering into a contract with a State agency if the contractor has been convicted of

bribery or attempting to bribe an officer or employee of the State of Illinois, or if the contractor has

made an admission of guilt of such conduct with is a matter of record. The contractor further

acknowledges that the chief procurement officer may declare the related contract void if this

certification is false.

2.0 BID-RIGGING/BID-ROTATING.

CONTRACTOR certifies that it has not been barred from contracting with a unit of State or

local government as a result of a violation of Section 33E-3 or 33E-4 of the Criminal Code of 1961

(720 ILCS 5/33E-3, 33E-4).

3.0 DRUG FREE WORKPLACE.

This certification is required by Section 3 of the Drug Free Workplace Act (30 ILCS 580/3).

The Drug Free Workplace Act, effective January 1, 1992, requires that CONTRACTOR shall not be

considered for the purposes of being awarded a contract for the procurement of any services from the

State unless CONTRACTOR has certified to the State that CONTRACTOR will provide a drug free

workplace. False certification or violation of the certification may result in sanctions including, but

not limited to, suspension of contract payments, termination of the contract and debarment of

contracting opportunities with the State for at least one (1) year but not more than five (5) years.

CONTRACTOR certifies and agrees that it will provide a drug free workplace by:

a. Publishing a statement:

i. Notifying employees that the unlawful manufacture, distribution, dispensation,

possession or use of a controlled substance, including cannabis, is prohibited in the

grantee’s or contractor’s workplace.

ii. Specifying the actions that will be taken against employees for violation of such

prohibition.

iii. Notifying the employee that, as a condition of employment on such contract or grant,

the employee will:

a. abide by the terms of the statement; and

b. notify the employer of any criminal drug statute conviction for a violation

occurring in the workplace no later than five (5) days after such conviction.

b. Establishing a drug free awareness program to inform employees about:

i. the dangers of drug abuse in the workplace;

ii. CONTRACTOR’s policy of maintaining a drug free workplace;

Revised on 4/12/2012

iii. any available drug counseling, rehabilitation, and employee assistance programs; and

iv. the penalties that may be imposed upon an employee for drug violations.

c. Providing a copy of the statement required by Section (a) to each employee engaging in the

performance of the contract or grant and to post the statement in a prominent place in the

workplace.

d. Notifying the Treasurer’s Office within ten (10) days after receiving notice under part (b) of

paragraph (iii) of Section (a) above from an employee or otherwise receiving actual notice of

such conviction.

e. Imposing a sanction on, or requiring the satisfactory participation in drug abuse assistance or

rehabilitation program by, an employee who is so convicted, as required by Section 5 of the

Drug Free Workplace Act.

f. Assisting employees in selecting a course of action in the event of drug counseling, treatment,

and rehabilitation is required and indicating that a trained referral team is in place.

g. Making a good faith effort to continue to maintain a drug free workplace through

implementation of the Drug Free Workplace Act.

4.0 U.S. EXPORT ACT.

CONTRACTOR certifies that neither CONTRACTOR nor any substantial-owned affiliated

company is participating or shall participate in an international boycott in violation of the provisions of

the U.S. Export Administration Act of 1979 (50 U.S.C.A. App. § 2401 et seq.) or the regulations of the

U.S. Department of Commerce promulgated under that Act.

5.0 NON-DISCRIMINATION.

CONTRACTOR certifies that it is in compliance with the State and Federal Constitutions, the

U.S. Civil Rights Act, Section 504 of the Federal Rehabilitation Act, and all applicable rules that

prohibit unlawful discrimination in performance of this Agreement and all other activities, including

employment and other contracts. As a condition of receiving the Agreement, CONTRACTOR

represents or certifies that services, programs and activities provided under the Agreement are and will

continue to be in compliance with State and Federal Constitutions, the U.S. Civil Rights Act, Section

504 of the Federal Rehabilitation Act, and all applicable laws that prohibit unlawful discrimination.

6.0 AMERICANS WITH DISABILITIES ACT.

CONTRACTOR certifies that it is in compliance with the Americans with Disabilities Act

(“ADA”) (42 U.S.C. 12101 et seq.) and the regulations thereunder (28 CFR 35.130) prohibit

discrimination against persons with disabilities by the Treasurer, whether directly or through

contractual arrangements, in the provision of any aid, benefit or service. As a condition of receiving

the Agreement, CONTRACTOR represents or certifies that services, programs and activities provided

under the Agreement are and will continue to be in compliance with the ADA.

7.0 ILLINOIS HUMAN RIGHTS ACT.

CONTRACTOR certifies that it is presently in compliance with all of the terms, conditions and

provisions of Section 5/2-105 of the Illinois Human Rights Act (775 ILCS 5/2-105), together with all

rules and regulations promulgated and adopted pursuant thereto.

Revised on 4/12/2012

8.0 FELONY.

CONTRACTOR certifies that it has not been barred from being awarded a contract under

Section 50-10 of the Illinois Procurement Code (30 ILCS 500/50-10). Section 50-10 prohibits a

contractor from entering into a contract with a State agency if the contractor has been convicted of a

felony and 5 years have not passed from the completion of the sentence for that felony. The contractor

further acknowledges that the chief procurement officer may declare the related contract void if this

certification is false.

9.0 FORMER EMPLOYMENT.

CONTRACTOR has informed the Treasurer’s Office in writing if CONTRACTOR was

formerly employed by the Treasurer’s Office and has received an early retirement incentive under

Section 14-108.3 or 16-133.3 of the Illinois Pension Code (30 ILCS 105/15a).

10.0 INDUCEMENT.

CONTRACTOR has not paid any money or valuable thing to induce any person to refrain from

bidding on a State contract, nor has CONTRACTOR accepted any money or other valuable thing, or

acted upon the promise of same, for not bidding on a State contract (30 ILCS 500/50-25).

11.0 REVOLVING DOOR PROHIBITION.

CONTRACTOR certifies that neither it nor its employees and agents are in violation of section

50-30 of the Illinois Procurement Code (30 ILCS 500/50-30). Section 50-30 prohibits for a period of

(2) years after terminating an affected position certain State employees and their designees from

engaging in any procurement activity relating to the State agency most recently employing them for a

specified period of time.

12.0 REPORTING ANTICOMPETITIVE PRACTICES.

CONTRACTOR shall report to the Illinois Attorney General and the Chief Procurement

Officer any suspected collusion or other anticompetitive practice among any bidders, offerors,

contractors, proposers or employees of the State (30 ILCS 500/50-40, /50-45, /50-50).

13.0 D

ISCRIMINATORY CLUB.

CONTRACTOR agrees not to pay any dues or fees on behalf of its employees or agents or

subsidize or otherwise reimburse them for payments of any dues or fees to a discriminating club as

prohibited by Section 2 of the Discriminatory Club Act (775 ILCS 25/2).

14.0 TAXPAYER IDENTIFICATION NUMBER AND LEGAL STATUS OF CONTRACTOR.

CONTRACTOR shall be in compliance with applicable tax requirements and shall be current

payment of such taxes. Under penalty of perjury, CONTRACTOR certifies that # is its

correct Taxpayer Identification Number and that it is doing business as a (please check one):

Revised on 4/12/2012

_____ Individual

_____ Sole Proprietor

_____Partnership/Legal Corporation

_____ Tax Exempt

_____ Corporation providing or billing

medical and/or health care services

_____ Corporation NOT providing or billing

medical and/or health care services

_____ Other:

15.0 LICENSE; AUTHORIZED BIDDER OR OFFEROR

_____ Government Entity

_____ Nonresident alien

_____ Estate or trust

_____ Pharmacy (Non-Corp.)

_____ Pharmacy/Funeral Home/Cemetery

(Corp.)

_____ Limited Liability Company (select

applicable tax classification.)

□ C = corporation

□ P = partnership

CONTRACTOR, directly or through its employees, shall have and maintain any license

required by this Agreement. CONTRACTOR further certifies that it is a legal entity authorized to do

business in Illinois prior to the submission of the bid, offer, or proposal pursuant to section 20-43 of

the Illinois Procurement Code (30 ILCS 500/20-43).

16.0 APPROPRIATION.

This Agreement is subject to termination and cancellation in any year for which the General

Assembly fails to make an appropriation for payments under the terms of the contract.

17.0 RECORDS RETENTION; RIGHT TO AUDIT.

CONTRACTOR agrees to maintain books and records related to the performance of the

contract and necessary to support amounts charged to the State under the contract for a minimum of

three years from the last action on the contract or after termination of the Agreement, whichever is

longer. Contractor further agrees to cooperate fully with any audit and to make the books and records

available for review and audit by the Auditor General, chief procurement officers, internal auditor and

the Treasurer; CONTRACTOR agrees to cooperate fully with any audit conducted by the Auditor

General or the Treasurer and to provide full access to all relevant materials. The three-(3)-year period

shall be extended for the duration of any audit in progress during the term. Failure to maintain the

books, records and supporting documents required by this Section shall establish a presumption in

favor of the State for the recovery of any funds paid by the State under this Agreement for which

adequate books, records, and supporting documentation are not available to support their purported

disbursement.

18.0 CONFLICTS OF INTEREST.

CONTRACTOR has disclosed, and agrees that it is under a continuing obligation to disclose, to

the Treasurer financial or other interests (public or private, direct or indirect) that may be a potential

conflict of interest that would prohibit CONTRACTOR from entering into or performing the

Agreement. Conflicts of interest include, but are not limited to, conflicts under Section 1400.5020 of

the Treasurer’s Procurement Rules (44 Ill. Adm. Code 1400.5020) and Sections 50-13, 50-20, and 50-

35 of the Illinois Procurement Code (30 ILCS 500/50).

Revised on 4/12/2012

19.0 LATE PAYMENTS.

Late payment charges, if any, shall not exceed the formula established in the Illinois Prompt

Payment Act (30 ILCS 540/1) and the Illinois Administrative Code (74 Ill. Adm. Code 900).

20.0 LIABILITY.

The State’s liability for damages is expressly limited by and subject to the provisions of the

Illinois Court of Claims Act (705 ILCS 505/1) and to the availability of suitable appropriations.

21.0 DEBT DELINQUENCY.

CONTRACTOR certifies that it, or any affiliate, is not barred from being awarded a contract or

subcontract under section 50-11 of the Illinois Procurement Code (30 ILCS 500/50-11). Section 50-11

prohibits a contractor from entering into a contract with the Treasurer’s Office if it knows or should

know that it, or any affiliate, is delinquent in the payment of any debt to the State as defined by the

Debt Collection Board. CONTRACTOR further acknowledges that the Treasurer’s Office may

declare the Agreement void if this certification is false or if CONTRACTOR or any affiliate is

determined to be delinquent in payment of any debt during the term of the Agreement.

22.0 EDUCATIONAL LOAN DEFAULT.

CONTRACTOR certifies that it is not barred from being awarded a contract under the

Educational Loan Default Act (5 ILCS 385). Section 3 of the Educational Loan Default Act prohibits

an individual from entering into a contract with the Treasurer’s Office if that individual is in default of

an educational loan. CONTRACTOR further acknowledges that the Treasurer’s Office may declare

the Agreement void if this certification is false or if CONTRACTOR is determined to be in default of

an educational loan during the term of the Agreement.

23.0 FORCE MAJEURE.

Failure by either party to perform its duties and obligations shall be excused by unforeseeable

circumstances beyond its reasonable control, including acts of nature, acts of the public enemy, riots,

labor or material shortages, labor disputes, fire, flood, explosion, legislation, and governmental

regulation.

24.0 A

NTITRUST ASSIGNMENT.

CONTRACTOR hereby assigns, sells and transfers to the State of Illinois all right, title and

interest in and to any claims and causes of action arising under antitrust laws of Illinois or the United

States relating to the subject matter of the Agreement.

25.0 P

ROHIBITION OF GOODS FROM FORCED LABOR.

CONTRACTOR certifies that it is not barred from being awarded a contract under the State

Prohibition of Goods from Forced Labor Act (30 ILCS 583). Section 10 of the State Prohibition of

Goods from Forced Labor Act prohibits a contractor from entering into a contract with the Treasurer’s

Revised on 4/12/2012

Office if that contractor knew that the foreign-made equipment, materials, or supplies furnished to the

State were produced in whole or part by forced labor, convict labor, or indentured labor under penal

sanction. CONTRACTOR further acknowledges that the Treasurer’s Office may declare the

Agreement void if this certification is false or if CONTRACTOR is determined to have known that the

foreign-made equipment, materials, or supplies furnished to the State during the term of the Agreement

were produced in whole or part by forced labor, convict labor, or indentured labor under penal

sanction.

26.0 PROHIBITION OF GOODS FROM CHILD LABOR.

CONTRACTOR certifies in accordance with Public Act 94-0264 that no foreign-made

equipment, materials, or supplies furnished to the State under the contract have been produced in

whole or in part by the labor of any child under the age of 12.

27.0 SARBANES-OXLEY ACT AND ILLINOIS SECURITIES LAW

CONTRACTOR certifies that it is not barred from being awarded a contract or subcontract

under section 50-10.5 of the Illinois Procurement Code (30 ILCS 500). Section 50-10.5, amongst

other things, prohibits a contractor from bidding or entering into a contract or subcontract with the

Treasurer’s Office if the contractor or any officer, director, partner, or other managerial agent of the

contractor has been convicted in the last 5 years of a felony under the Sarbanes-Oxley Act of 2002 or a

Class 3 or Class 2 felony under the Illinois Securities Law of 1953 or if the contractor is in violation of

Subsection (e). CONTRACTOR further acknowledges that the Treasurer’s Office may declare the

agreement void if this certification is false or if CONTRACTOR is determined to have been convicted

of a felony under the Illinois Sarbanes-Oxley Act of 2002 or a Class 3 or Class 2 felony under the

Illinois Securities Law of 1953 during the term of the agreement.

28.0 DISPUTES.

Any claim against the State arising out of this Agreement must be filed exclusively with the

Illinois Court of Claims (705 ILCS 505/1). The State shall not enter into binding arbitration to resolve

any agreement dispute. The State of Illinois does not waive sovereign immunity by entering into this

Agreement. Any provision containing a citation to an Illinois statute (cited “ILCS”) may not contain

the complete statutory language. The official text, which is incorporated by reference, may be found in

the appropriate chapter and section of the Illinois Compiled Statutes. An unofficial version may be

viewed at www.ilga.gov.

29.0 THIRD-PARTY PAYMENTS.

CONTRACTOR certifies that no fee was paid to a third-party in expectation of being awarded

a contract by the Treasurer.

30.0 MOST FAVORABLE TERMS.

If more favorable terms are granted by the CONTRACTOR to any similar governmental agency

in any state in a contemporaneous agreement let under the same or similar financial terms and

Revised on 4/12/2012

circumstances for comparable supplies or services, the more favorable terms will be applicable under

the Agreement between the Treasurer’s Office and the CONTRACTOR.

31.0 BOARD OF ELECTIONS REGISTRATION

____ The CONTRACTOR certifies that they are not required to register as a business entity with

the State Board of Elections pursuant to the Illinois Procurement Code (30 ILCS 500/20-160). Further,

the CONTRACTOR acknowledges that all contracts or subcontracts between State agencies and a

business entity that do not comply with this Section shall be voidable under Section 50-60 of the

Illinois Procurement Code (30 ILCS 500/50-60).

(or)

____ The CONTRACTOR certifies that they have registered as a business entity with the State

Board of Elections and acknowledges a continuing duty to update the registration pursuant to the

Illinois Procurement Code (30 ILCS 500/20-160). Further, the CONTRACTOR acknowledges that all

contracts or subcontracts between State agencies and a business entity that do not comply with this

Section shall be voidable under Section 50-60 of the Illinois Procurement Code (30 ILCS 500/50-60).

32.0 COLLECTION AND REMITTANCE OF ILLINOIS USE TAX

The CONTRACTOR certifies that it is not barred from being awarded a contract under section

50-12 of the Illinois Procurement Code (30 ILCS 500/50-12). Section 50-12 prohibits a contractor

from entering into a contract or subcontract with a State agency if the CONTRACTOR or affiliate has

failed to collect and remit Illinois Use Tax on all sales of tangible personal property into the State of

Illinois in accordance with the provisions of the Illinois Use Tax Act. The CONTRACTOR further

acknowledges that the contract or subcontract may be voided if this certification is false.

33.0 ENVIRONMENTAL PROTECTION ACT VIOLATIONS

The CONTRACTOR certifies that it is not barred from being awarded a contract or subcontract

under section 50-14 of the Illinois Procurement Code (30 ILCS 500/50-14). Section 50-14 prohibits a

CONTRACTOR from entering into a contract or subcontract with a State agency if the

CONTRACTOR has been found by a court or the Pollution Control Board to have committed a willful

or knowing violation of the Environmental Protection Act within the last (5) years. The

CONTRACTOR further acknowledges that the contracting State agency may declare the related

contract or subcontract void if this certification is false.

34.0 LEAD POISONING PREVENTION ACT VIOLATIONS

The CONTRACTOR certifies that it is not barred from entering into a contract or subcontract

under section 50-14.5 of the Illinois Procurement Code (30 ILCS 500/50-14.5). Section 50-14.5

prohibits a CONTRACTOR from entering into a contract or subcontract with the State of Illinois or a

State agency if the CONTRACTOR, while the owner of a residential building, committed a willful or

knowing violation of the Lead Poisoning Prevention Act. The CONTRACTOR further acknowledges

that the Treasurer may declare the related contract or subcontract void if this certification is false.

Revised on 4/12/2012

35.0 BOND ISSUANCES

The CONTRACTOR certifies that it is not barred from being awarded a contract or subcontract

under section 50-21 of the Illinois Procurement Code (30 ILCS 500/50-21). Section 50-21 prohibits

State agencies from entering into contracts or subcontracts with respect to the issuances of bonds or

other securities by the State or a State agency with any entity that uses an “independent consultant” as

defined in section 50-21.

36.0 POLITICAL CONTRIBUTIONS

The CONTRACTOR certifies that it is not barred from being awarded a contract or subcontract

under section 50-37 of the Illinois Procurement Code (30 ILCS 500/50-37). Section 50-37 prohibits

business entities whose contracts with State agencies, in the aggregate, annually total more than

$50,000, or whose aggregate pending bids and proposals on State contracts total more than $50,000,

and any affiliated entities or affiliated persons of such business entity, from making any contributions

to any political committee established to promote the candidacy of the office holder responsible for

awarding the contract on which the business entity has submitted a bid or proposal during the period

beginning on the date the invitation for bids or request for proposals are issued and ending on the day

after the date the contract is awarded.

37.0 LOBBYING RESTRICTIONS

The CONTRACTOR certifies that it is not barred from being awarded a contract or subcontract

under section 50-38 of the Illinois Procurement Code (30 ILCS 500/50-38). Section 50-38 prohibits a

CONTRACTOR from billing the State for any lobbying costs, fees, compensation, reimbursements, or

other remuneration provided to any lobbyist who assisted the CONTRACTOR in obtaining the

contract or subcontract.

38.0 DISCLOSURE OF BUSINESS OPERATIONS WITH IRAN (30 ILCS 500/50-36)

Each bid, offer, or proposal submitted for a State contract, other than a small purchase defined in

Section 20-20 [of the Illinois Procurement Code], shall include a disclosure of whether or not the bidder,

offeror, or proposing entity, or any of its corporate parents or subsidiaries, within the 24 months before

submission of the bid, offer, or proposal had business operations that involved contracts with or provision of

supplies or services to the Government of Iran, companies in which the Government of Iran has any direct or

indirect equity share, consortiums or projects commissioned by the Government of Iran and:

(1) more than 10% of the company’s revenues produced in or assets located in Iran involve oil-related

activities or mineral-extraction activities; less than 75% of the company’s revenues produced in or assets

located in Iran involve contracts with or provision of oil-related or mineral – extraction products or services

to the Government of Iran or a project or consortium created exclusively by that Government; and the

company has failed to take substantial action; or

(2) the company has, on or after August 5, 1996, made an investment of $20 million or more, or any

combination of investments of at least $10 million each that in the aggregate equals or exceeds $20 million

in any 12- month period that directly or significantly contributes to the enhancement of Iran’s ability to

develop petroleum resources of Iran.

Revised on 4/12/2012

___________________________________________

You must check one of the following items and if item 2 is checked you must also make the necessary

disclosure:

___ There are no business operations that must be disclosed to comply with the above cited law.

___ The following business operations are disclosed to comply with the above cited law:

CONTRACTOR

By:

Signature

Name

Title

Date

Revised on 4/12/2012

Appendix B

DISCLOSURES

FINANCIAL INTEREST AND POTENTIAL CONFLICTS OF INTEREST

(Disclosure Form A)

The Treasurer’s Procurement Regulations (44 Ill. Adm. Code 1400.5035) require that

contractors/offerors desiring to enter into certain contracts with the State of Illinois

must disclose the financial and potential conflicts of interest information as specified

below.

Contractor/offeror shall disclose the financial interest and potential conflicts of interest

information identified in Sections 1 and 2 below as a condition of receiving an award

or contract. Submit this information along with your bid, proposal or offer.

This requirement applies to contracts with an annual value exceeding $10,000.

A publicly traded entity may submit its 10K disclosure in satisfaction of the disclosure

requirements set forth in both

Sections 1 and 2 below.

Sec. 1. Disclosure of Financial Interest in the Contractor/Offeror

a. If any individuals have one of the following financial interests in the

contractor/offeror (or its parent), please check all that apply

and show

their name and address:

Ownership exceeding 5% (_____)

Ownership value exceeding $106,447.20

(_____)

Distributive Income Share exceeding 5% (_____)

Distributive Income Share exceeding $106,447.20 (_____)

Name: ____________________________________________________

Address: ____________________________________________________

b. For each indi

vidual named above, show the type of ownership/distributable

income share: sole proprietorship _____ stock _____ partnership _____

other (explain)

______________________________________________________.

c. For each individual named above, show the dollar

value or proportionate

share of the ownership interest in the contractor/offeror (or its parent) as

follows:

If the pro

portionate share of the named individual(s) in the ownership of

the

contractor/offeror (or its

parent) is 5% or less, and

if the value of the

ownership interest of the named individual(s) is $106,447.20 or less, check

here (_____)

If the proportionate share of ownership exceeds 5% or the value of the

ownership interest exceeds $106,447.20, show either.

The percent of ownership __________%

The value of the ownership interest $___________

Sec. 2. Disclosure of Potential Conflicts of Interest. For each of the individuals having the

level of financial interest identified in Section 1 above, check “Yes” or “No” to

indicate which, if any, of the following potential conflicts of interest relationships

apply. If “Yes,” please describe (use space under applicable section to explain your

answers – attach additional pages as necessary).

a. State employment, currently or in the previous 3 Yes No

years, including contractual employment of services _____ _____

b. State employment for spouse, father, mother, son, or Yes No

daughter, including contractual employme

nt for

_____ _____

services in the previous 2 years.

c. Elective status; the holding of elective office of the Yes No

State of Illinois, the government of the United States,

_____

any unit of local government authorized by

the

Constitution of the State of Illinois, or the statutes of

the State of Illinois currently or in the previous 3 years.

d. Relationship to anyone holding elective office Yes No

currently or in the previous 2 years; spouse, father, _____ _____

mother, son, or daugh

ter.

Appointive office; the holding of any appointive

Yes

government office of the State of Illinois, the United

_____ _____

States of America, or any unit of local govern

ment

authorized by the Constitution of the State of Illinois or

the statutes of the State of Illinois, which office entitles

the holder to compensation in excess of expenses

incurred in the discharge of that office currently or in

the previous 3 years.

Relationship to anyone holding appointiv

e office

Yes No

currently or in the previous 2 y

ears; spouse, father,

_____ _____

mother, son, or daugh

ter.

Employment, currently or in the previous 3 years, as

Yes

or by any registered lobbyist of the State _____ _____

government.

h. Relationship to anyone who is or was a registered Yes No

lobbyist in the previous 2 years; spouse, father, _____ _____

mother, son, or daughter.

i. Compensated employme

nt, currently or in the

Yes No

previous 3 years, by any registered election or re- _____ _____

election committee registered with the Secretary

_______________________________________________

State or any county clerk in the State of Illinois, or

any political action committee with either

the Secretary of State or the Federal Board of

Elections.

Relationship to anyone; spouse, father, mo

ther, son,

Yes No

or daughter, who is or was a compensated employee _____ _____

in the last 2 years of any registered election or re-

election committee registered with the Secretary of

State or any county clerk in the State of Illinois, or

any political action committee registered with either

the Secretary of State or the Federal Board of

Elections.

This disclosure is submitted on behalf of

(Name of Contractor/Offeror)

Official authorized to sign on behalf of contractor/offeror:

Name (printed) ____________________________________Title ________________________

Signature ________________________________________ Date _______________________

Appendix C

DISCLOSURES

OTHER CONTRACT AND PROCUREMENT RELATED INFORMATION

(Disclosure Form B)

The Treasurer’s Procurement Regulations (44 Ill. Adm. Code 1400.5035) require that

contractors/offerors desiring to enter into certain contracts with the State of Illinois must disclose

the information as specified below.

Contractor/offeror shall disclose the information identified below as a condition of receiving an

award or contract.

This requirement is applicable to only those contracts with an annual value exceeding $10,000.

You must submit this information along with your bid, proposal or offer.

a. Contractor/offeror shall identify whether it h

as current contracts (including leases) with

other units of

State of Illinois government by checking “Yes”_____

or “No” _____.

If “Yes

” is checked, identify each contract by

showing agency name and other descriptive

information such as purchase order or contract reference number (attach additional pages

as necessary).

b. Contractor/offeror shall identify whether it has pending contracts (including leases), bids,

proposals, or other ongoing procurement relationships with other units of State of Illinois

government by checking “Yes” _____ or “No” _____.

If “Yes

” is checked, identify each such relationship by showing agency name an

d other

descriptive information such as bid or

project number

(attach additional pages as

necessary).

This disclosure is submitted on behalf of ____________________________________________

(Name of Contractor/Offeror)

Official authorized to sign on behalf of contractor/offeror:

Name (printed) ____________________________________ Title _______________________

Signature ________________________________________ Date_______________________

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