Fillable Vendor Disclosure Statement Information and Instructions Act 2001-955 (Shelton State Community College)

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Vendor Disclosure Statement Information and Instructions Act 2001-955 (Shelton State Community College)

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Vendor Disclosure Statement Information and Instructions
Act 2001-955 requires the disclosure statement to be completed and filed with all proposals, bids, contracts, or
grant proposals to the State of Alabama in excess of $5,000. The disclosure statement is not required for
contracts for gas, water, and electric services where no competition exits, or where rates are fixed by law or
ordinance. In circumstances where a contract is awarded by competitive bid, the disclosure statement shall be
required only from the person receiving the contract and shall be submitted within ten (10) days of the award.
A copy of the disclosure statement shall be filed with the awarding entity and the Department of Examiners of
Public Accounts and if it pertains to a state contract, a copy shall be submitted to the Contract Review
Permanent Legislative Oversight Committee. The address for the Department of Examiners of Public Accounts
is as follows: 50 N. Ripley Street, Room 3201, Montgomery, Alabama 36130-2101. If the disclosure statement
is filed with a contract, the awarding entity should include a copy with the contract when it is presented to the
Contract Review Permanent Legislative Oversight Committee.
The State of Alabama shall not enter into any contract or appropriate any public funds with any person who
refuses to provide information required by Act 2001-955.
Pursuant to Act 2001-955, any person who knowingly provides misleading or incorrect information on the
disclosure statement shall be subject to a civil penalty of ten percent (10%) of the amount of the transaction, not
to exceed $10,000.00. Also, the contract or grant shall be voidable by the awarding entity.
Definitions as Provided in Act 2001-955
Family Member of a Public Employee - The spouse or a dependent of the public employee.
Family Member of a Public Official - The spouse, a dependent, an adult child and his or her spouse, a parent,
a spouse's parents, a sibling and his or her spouse, of the public official.
Family Relationship - A person has a family relationship with a public official or public employee if the person
is a family member of the public official or public employee.
Person - An individual, firm, partnership, association, joint venture, cooperative, or corporation, or any other
group or combination acting in concert.
Public Official and Public Employee - These terms shall have the same meanings ascribed to them in
Sections 36-25-1(23) and 36-25-1(24), Code of Alabama 1975, (see below) except for the purposes of the
disclosure requirements of this act, the terms shall only include persons in a position to influence the awarding
of a grant or contract who are affiliated with the awarding entity. Notwithstanding the foregoing, these terms
shall also include the Governor, Lieutenant Governor, members of the cabinet of the Governor, and members of
the Legislature.
Section 36-25-1(23), Code of Alabama 1975, defines a public employee as any person employed at the state,
county or municipal level of government or their instrumentalities, including governmental corporations and
authorities, but excluding employees of hospitals or other health care corporations including contract employees
of those hospitals or other health care corporations, who is paid in whole or in part from state, county, or
municipal funds. For purposes of this chapter, a public employee does not include a person employed on a part-
time basis whose employment is limited to providing professional services other than lobbying, the
compensation for which constitutes less than 50 percent of the part-time employee's income.
Section 36-25-1(24), Code of Alabama 1975, defines a public official as any person elected to public office,
whether or not that person has taken office, by the vote of the people at state, county, or municipal level of
government or their instrumentalities, including governmental corporations, and any person appointed to a
position at the state, county, or municipal level of government or their instrumentalities, including governmental
corporations. For purposes of this chapter, a public official includes the chairs and vice-chairs or the equivalent
offices of each state political party as defined in Section 17-16-2, Code of Alabama 1975.
Instructions
Complete all lines as indicated. If an item does not apply, denote N/A (not applicable). If you cannot include
required information in the space provided, attach additional sheets as necessary.
The form must be signed, dated, and notarized prior to submission.
ENTITY COMPLETING FORM
ADDRESS
CITY, STATE, ZIP TELEPHONE NUMBER
()
STATE AGENCY/DEPARTMENT THAT WILL RECEIVE GOODS, SERVICES, OR IS RESPONSIBLE FOR GRANT AWARD
ADDRESS
CITY, STATE, ZIP TELEPHONE NUMBER
()
This form is provided with:
Contract
Proposal
Request for Proposal
Invitation to Bid
Grant Proposal
Have you or any of your partners, divisions, or any related business units previously performed work or provided goods to any State
Agency/Department in the current or last fiscal year?
Ye s
No
If yes, identify below the State Agency/Department that received the goods or services, the type(s) of goods or services previously pro-
vided, and the amount received for the provision of such goods or services.
STATE AGENCY/DEPARTMENT TYPE OF GOODS/SERVICES AMOUNT RECEIVED
Have you or any of your partners, divisions, or any related business units previously applied and received any grants from any State
Agency/Department in the current or last fiscal year?
Ye s
No
If yes, identify the State Agency/Department that awarded the grant, the date such grant was awarded, and the amount of the grant.
STATE AGENCY/DEPARTMENT DATE GRANT AWARDED AMOUNT OF GRANT
1. List below the name(s) and address(es) of all public officials/public employees with whom you, members of your immediate family, or
any of your employees have a family relationship and who may directly personally benefit financially from the proposed transaction.
Identify the State Department/Agency for which the public officials/public employees work. (Attach additional sheets if necessary.)
NAME OF PUBLIC OFFICIAL/EMPLOYEE ADDRESS STATE DEPARTMENT/AGENCY
State of Alabama
Disclosure Statement
(Required by Act 2001-955)
OVER
AIDT
One Technology Court
Montgomery, AL 36116-3200
334
242-4158
(Purchase Order)
2. List below the name(s) and address(es) of all family members of public officials/public employees with whom you, members of your
immediate family, or any of your employees have a family relationship and who may directly personally benefit financially from the
proposed transaction. Identify the public officials/public employees and State Department/Agency for which the public officials/public
employees work. (Attach additional sheets if necessary.)
NAME OF NAME OF PUBLIC OFFICIAL/ STATE DEPARTMENT/
FAMILY MEMBER ADDRESS PUBLIC EMPLOYEE AGENCY WHERE EMPLOYED
If you identified individuals in items one and/or two above, describe in detail below the direct financial benefit to be gained by the public
officials, public employees, and/or their family members as the result of the contract, proposal, request for proposal, invitation to bid, or
grant proposal. (Attach additional sheets if necessary.)
Describe in detail below any indirect financial benefits to be gained by any public official, public employee, and/or family members of the
public official or public employee as the result of the contract, proposal, request for proposal, invitation to bid, or grant proposal. (Attach
additional sheets if necessary.)
List below the name(s) and address(es) of all paid consultants and/or lobbyists utilized to obtain the contract, proposal, request for pro-
posal, invitation to bid, or grant proposal:
NAME OF PAID CONSULTANT/LOBBYIST ADDRESS
By signing below, I certify under oath and penalty of perjury that all statements on or attached to this form are true and correct
to the best of my knowledge. I further understand that a civil penalty of ten percent (10%) of the amount of the transaction, not
to exceed $10,000.00, is applied for knowingly providing incorrect or misleading information.
Signature Date
Notary’s Signature Date Date Notary Expires
Act 2001-955 requires the disclosure statement to be completed and filed with all proposals, bids, contracts, or grant proposals to the
State of Alabama in excess of $5,000.
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Vendor Disclosure Statement Information and Instructions Act 2001-955 (Shelton State Community College)

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Completed 25 July 2020

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