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Sheet: Sheet1

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Failure to complete all of the following information may result in a delay in obtaining a contract, lease, purchase agreement, or grant award with any Arkansas State Agency.
 |  | Social Security Number |  |  | Federal ID Number |  | Subcontractor |  | Subcontractor Name:
Taxpayer ID# |  |  |  | or |  |  | Yes | No
 |  |  |  |  |  |  | Is This For:
Taxpayer ID Name: |  |  |  |  |  |  | Goods? |  | Service? |  | Both?
Your Last Name: |  |  |  |  | First Name: |  |  |  | M.I.:
Address:
City: |  |  |  | State: |  |  | Zip: |  | Country:
AS A CONDITION OF OBTAINING, EXTENDING, AMENDING, OR RENEWING A CONTRACT, LEASE, PURCHASE AGREEMENT, OR GRANT
AWARD WITH ANY ARKANSAS STATE AGENCY, THE FOLLOWING INFORMATION MUST BE DISCLOSED.
FOR INDIVIDUALS*
Indicate below if: you, your spouse or the brother, sister, parent, or child of you or your spouse is a current or former: member of the General Assembly,
Constitutional Office, State Board or Commission Member, or State Employee:
Position Held |  | Mark (x) |  | Name of Position of Job Held (senator, representative, name of board/commission, data entry, etc.) |  |  | For How Long? |  | What is the person(s) name and how are they related to you? ('i.e., [NAME],  spouse, [NAME], Jr., child, etc.)
 |  | Current | Former |  |  |  | From MM/YY | To MM/YY | Person's Name(s) |  | Relation
General Assembly
Constitutional Officer
State Board or
Commission Member
State Employee
 | None of the above applies
FOR AN ENTITY (BUSINESS)*
Position Held |  | Mark (x) |  | Name of Position of Job Held (senator, representative, name of board/commission, data entry, etc.) |  |  | For How Long? |  | What is the person(s) name and how are they related to you? ('i.e., [NAME],  spouse, [NAME], Jr., child, etc.)
 |  | Current | Former |  |  |  | From MM/YY | To MM/YY | Person's Name(s) |  | Relation
General Assembly
Constitutional Officer
State Board or
Commission Member
State Employee
 | None of the above applies
*NOTE: PLEASE LIST ADDITIONAL DISCLOSURES ON SEPARATE SHEET OF PAPER IF MORE SPACE IS NEEDED
Failure to make any disclosure required by Governor's Executive Order 98-04, or any violation of any rule, regulation, or policy adopted pursuant
to that [NAME], shall be a material breach of the terms of this contract.  Any contractor, whether an individual or entity, who fails to make the required
disclosure or who violates any rule, regulation, or policy shall be subject to all legal remedies available to the agency.
As an additional condition of obtaining, extending, amending, or renewing a contract with a state agency I agree as follows:
1. | Prior to entering into any agreement with any subcontractor, prior or subsequent to the contract date, I will require the subcontractor to
complete a Contract And Grant Disclosure And Certification Form.  Subcontractor shall mean any person or entity with whom I enter an agreement
whereby I assign or otherwise delegate to the person or entity, for consideration, all, or any part, of the performance required of me under the terms of
my contract with the state agency.
2. | I will include the following language as part of any agreement with a subcontractor:
 | Failure to make any disclosure required by Governor's Executive Order 98-04, or any violation of any rule, regulation, or policy adopted
 | pursuant to the [NAME], shall be a material breach of the terms of the subcontract.  The party who fails to make the required disclosure or who
 | violates any rule, regulation, or policy shall be subject to all legal remedies available to the contractor.
3. | No later than ten (10) days after entering into any agreement with a subcontractor, whether prior or subsequent to the contract date, I will
 | mail a copy of the Contract and Grant Disclosure and Certification Form completed by the subcontractor and a statement containing the dollar
 | amount of the subcontract to the state agency.
I certify under penalty of perjury, to the best of my knowledge and belief, all of the above information is true and correct
and that I agree to the subcontractor disclosure conditions stated herein.
Signature |  |  |  |  |  | Title |  |  |  |  | Date
Entity Contact Person |  |  |  |  |  | Title |  |  |  |  | Date
AGENCY USE ONLY
Agency |  |  | Agency |  |  | Agency Contact |  |  | Contract |  |  | Contract or
Number |  |  | Name |  |  | Person |  |  | Phone No. |  |  | Grant No.
FORMS AVAILABLE FROM OFFICE OF DISCLOSURE AND REVIEW (501) 682-5407