Fillable Venor Disclosure Statement (Alabama A&M University)

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Venor Disclosure Statement (Alabama A&M University)

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Vendor
Discloeure
Statement Information
and
lnstructions
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
statemenl shall
be filed with
the
awarding entity
and the
Department
of Examiners
of
Public
Accounts and if it
pertains
to a
state
contact,
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.
lf
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
disclosurestatementshall
besubjecttoacivil
penattyof
ten
percent(10%)of
theamountof
thetransaction,
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
orcombination acting
in
concert.
Public
Official and Public
Employee -
These terms
shall
have the
same meanings
ascribed to them
in
Sections 36t5-1(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
govemmenl
or their
instrumentalities,
including
governmental
corporations
and
authorities,
but
excluding employees
of
hospitals
or other
health
care
corpbrations
including
iontract
employees
of
those hospitals
or other health
care corporations,
who is
paid
in
whole or in
part
lrom
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
employmenl is limited
to
providing
professional
services
other
than lobbying,
the
compensation
for
which conslitutes
less than
50
percent
of the
part-time
employee's
income.
Section 36A5-1
(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.
lnstructions
Complete all lines as indicated.
lf an
item
does
not apply, denote N/A
(notapplicable).
lf
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.
State
of
Alabama
Disclosure
Statement
(Required
by
Act 20}b95r)
ENTITY COMPLETING FORI\4
TELEPHONE
NUMBER
()
CIry STATE, ZIP
srere ncrruc*7:
TELEPHONE
NUI\4BER
1\
\/
crry STATE, ZtP
This
form is
provided
with:
I
Contract l-l
Proposat
I
nequest for
proposat
l-l
Invitation
to Bid
I
Cr"nt
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?
I
v""
Iruo
lf
yes,
identiry
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.
Agency/Department
in
the current or last
fiscal
year?
I
v""
[
,.ro
lf
yes,
identif
the
State AgencylDepartment
that awarded
the
grant,
the date such
grant
was awarded,
and the amount
of the
qrant
any of
your
employees
have a hmily relationship
and who
may directly
personally
benefit financially
from the
proposed
transaction.
ldentiff the
State DepartmenVAgency for
which
the
public
officials/public employees
work.
(Attach
additional sheets
if necessary.)
OYER
n List below
the name(s)
and
address(es)
of all tumily
members
of
public
officials/public
employees
with whom
you,
members
of
your
immediate family,
or any of
your
employees
have a
fumily
relationship and who
may directly
personally
benefit
financially from
the
proposed
transaction. ldentin/
the
public
officialsipublic
employees
and State
DepartmenilAgency
for
which the
public
officials/public
employees
work.
(Attach
additional sheets
if necessary.)
lf
you
identified
individuals
in items one
and/ortwo
above,
describe in detail below
the
directfinancial
benefitto 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.)
public
official or
public
employee as the result
of the contract,
proposal,
request for
proposal,
invitation
to bid,
or
grant
proposat.
(Attach
additional sheets
if necessary.)
List below
the name(s)
and address(es)
of
all
paid
consultants
and/or lobbyists utilired
to
obtain the contmct,
proposal,
request
for
pro-
posal,
invitation
to
bid, or
grant proposal:
By signing
below,
I certify
under oath
and
penalty
of
perjury
that att statements
on
or attached
to this form
are
true
and correct
to the best
of my
knowledge.
I further anderstand
that
a
civil
penatty
of ten
percent
(10o/o)
of the
amount of
the transaction,
not
to exceed
$10,000.00,
is
applied for knowingly
providing
incorrect
or misleading
information.
Signature
Date
NotaryF
Signature
Date Date
Notary
Eaires
Act 2001'955
requires
the disclosure
statement
ta be completed
and
filed with
all
praposals,
bids, contracts,
or
grant
proposals
fo fhe
State of
Alabama
in
excess
of $5.000.
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Venor Disclosure Statement (Alabama A&M University)

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Completed 27 July 2020

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