Department No.: Contract ID#: (DYCD USE ONLY) EPIN: Term of Agreement: Total Contract Amount: Name of Contractor: Address: MOC ID(s): Type of Service: Type of Procurement: DISCRETIONARY- over $100,000 THIS AGREEMENT, effective July 1, 2015, between the CITY OF NEW YORK (“City”) acting by and through its Department of Youth and Community Development (“Department”), having an office located at 2 Lafayette Street, New York, New York 10007, and (“Contractor”) a not-for-profit corporation having its principal office located at .
Trips: Awards: Bank Charges: Admissions/Entrance Fees: Subscription Costs: Computer set-up/ wiring costs: Participant t-shirts or uniforms: Publication fees: General Liability Insurance: Sporting or recreational supplies: Printing: Audit Fees: Refreshments/ Food: Postage: Other (describe in detail): (Please attach additional pages as needed)
Contracting Agency. If there are any material changes to programming or key staff please attach an explanation to this form. NOTE: If you have any questions about your prequalification status or the date of your last submission, please check the DYCD List of Prequalification Clearances at I , being duly sworn, state on behalf of the submitting organization that no material changes in programming or key staff have occurred since the last submission of the Prequalification/Recertification Application OR if material changes in programming or key staff have occurred since the last submission they are fully described on the attached pages. I understand that the City of New York will rely on the information supplied in this certification for discretionary funding purposes. Name of Nonprofit Organization (Vendor) Signature of Authorized Officer Vendor's Address Print Name / Title of Signer City / State / Zip Code Vendor's EIN Phone Number Email Address Bill de Blasio Mayor Lisette Camilo City Chief Procurement Officer and Director of Contract Services 253 Broadway, 9th Floor New York, NY 10007 212 788 0001 tel 212 788 0049 fax Conflict of Interest Disclosure and Compliance Certification A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THlS CERTlFICATION, AND/OR THE FAILURE TO CONDUCT APPROPRlATE DUE DILIGENCE IN VERIFYNG THE lNFORMATlON THAT IS THE SUBJECT MATTER OF THIS CERTIFICATION, MAY RESULT IN RENDERING THE VENDOR NON-RESPONSIBLE FOR THE PURPOSE OF CONTRACT AWARD, AND A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS CERTIFlCATlON MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRlMlNAL CHARGES. No Conflict of Interest: Except as otherwise fully disclosed below (attach additional pages as needed), the Vendor affirms, to the best of its knowledge, information and belief, that no City Elected Official, nor any person associated with any City Elected Official, is an employee, Director or Trustee, Officer or consultant to/of, or has any financial interest, direct or indirect, in the organization, or has received or will receive any financial benefit, directly or indirectly, from the organization or from this funding. For purposes of this certification, "associated”
The City of New York Mayor's Office of Contract Services Doing Business Accountability Project To be completed by the City Agency prior to distribution Agency: Transaction ID: Check One: Transaction Type (check one): Doing Business Data Form Proposal Award Contract Grant Economic Agreement Pension Investment Contract Any entity receiving, applying for or proposing on an award or agreement must complete a Doing Business Data Form (see Q&A sheet for more information). Please either type responses directly into this fillable form or print answers by hand in black ink, and be sure to fill out the certification box on the last page. Submission of a complete and accurate form is required for a proposal to be considered responsive or for any entity to receive an award or enter into an agreement. This Data Form requires information to be provided on principal officers, owners and senior managers. The name, employer and title of each person identified on the Data Form will be included in a public database of people who do business with the City of New York; no other information reported on this form will be disclosed to the public. This Data Form is not related to the City's VENDEX requirements. Please return the completed Data Form to the City Agency that supplied it. Please contact the Doing Business Accountability Project at or 212-788-8104 with any questions regarding this Data Form. Thank you for your cooperation. Section 1: Entity Information Entity Name: Entity EIN/TIN: Entity Filing Status (select one): Entity has never completed a Doing Business Data Form. Fill out the entire form. Change from previous Data Form dated . Fill out only those sections that have changed, and indicate the name of the persons who no longer hold positions with the entity. No Change from previous Data Form dated . Skip to the bottom of the last page. Entity is a Non-Profit: Yes No Entity Type: Corporation (any type) Sole Proprietor Joint Venture Other (specify): LLC Partnership (any type) Address: City: State: Zip: Phone: Fax: