Disclosure of Prior Findings of Non-responsibility Form

(Mandatory)

Name of Individual or Entity seeking to enter the procurement contract:
Address:
Date:
Solicitation or Agreement Number:

Name and Title of Person Submitting this Form:
Has any Governmental Entity made a finding of non-
responsibility regarding the Individual or Entity seeking to enter the Procurement Contract in the last four years?

(Please indicate with an "X")	Yes
No
Was the basis for the finding of non-responsibility due to due to a violation of §139-j of the State Finance Law?

(Please indicate with an "X")	Yes
No
Was the basis for the finding of non-responsibility due to the intentional provision of false or incomplete information to a Governmental Entity? (Please indicate with an "X")	Yes
No
If you answered yes to any of the above questions, please provide details regarding the finding of non-responsibility below.
Government Agency or Authority:
Date of Finding of Non-responsibility:
Basis of Finding of Non-responsibility: (Add additional pages as necessary)

Has any Government al Entity or other governmental agency terminated or withheld a Procurement Contract with the above-named Individual or Entity due to the intentional provision of false or incomplete information ? (Please indicate with an "X")

(Please indicate with an "X")	Yes
No
If you answered yes, please provide details below.
Government Agency or Authority:
Date of Termination or Withholding of Contract:
Basis of Termination or Withholding: (Add additional pages as necessary)

Offerer certifies that all information provided to NYSERDA with respect to State Finance Law §139-k is complete, true, and accurate.

By:__________________________________ Date:_______________________________

Signature

Name:________________________________ Title:_______________________________