Certificate Of No Change Form – Fill Out and Use This PDF

Certificate of No Change Form

•Please fill in all the fields and DO NOT leave any field blank.

•Please submit two completed forms. Copies will not be accepted.

•Please send both copies to the agency that requested it, unless you are advised to send it directly to the Mayor’s Office of Contract Services (MOCS).

•A materially false statement willfully or fraudulently made in connection with this certification, and/or the failure to conduct appropriate due diligence in verifying the information that is the subject of this certification, may result in rendering the submitting entity non-responsible for the purpose of contract award.

•A materially false statement willfully or fraudulently made in connection with this certification may subject the person making the false statement to criminal charges

I, _____________________________________________, being duly sworn, state that I have read

Enter Your Name

and understand all the items contained in the vendor questionnaire and any submission of change as identified on page one of this form and certify that as of this date, these items have not changed. I further certify that, to the best of my knowledge, information and belief, those answers are full, complete, and accurate; and that, to the best of my knowledge, information, and belief, those answers continue to be full, complete, and accurate.

In addition, I further certify on behalf of the submitting vendor that the information contained in the principal questionnaire(s) and any submission of change identified on page two of this form have not changed and have been verified and continue, to the best of my knowledge, to be full, complete and accurate.

I understand that the City of New York will rely on the information supplied in this certification as additional inducement to enter into a contract with the submitting entity.

Vendor Questionnaire This section is required.

This refers to the vendor questionnaire(s) submitted for the vendor doing business with the City.

Name of Submitting Entity: ________________________________________________________

Vendor’s Address: ________________________________________________________________

Vendor’s EIN or TIN: _____________________ Requesting Agency: ________________________

Are you submitting this Certification as a parent? (Please circle one) Yes No

Signature date on the last full vendor questionnaire signed by the submitting vendor: ___________

Signature date on changed submission, if applicable, for the submitting vendor: _______________

Mayor’s Office of Contract Services	1
253 Broadway, 9th Floor New York, NY 10007
Phone: 212 788 0018 Fax: 212 788 0049

Principal Questionnaire

This section refers to the most recent principal questionnaire submissions.

	Date of signature	Date(s) of signature on
Principal Name	on last full Principal	Changed Submission
	Questionnaire	(if applicable)

1

2

3

4

5

6

Check if additional changes were submitted and attach a document with the date of additional submissions.

Certification This section is required.

This form must be signed and notarized. Please complete this twice. Copies will not be accepted.

Certified By:

____________________________________________________________________________

Name (Print)

____________________________________________________________________________

Title

____________________________________________________________________________

Name of Submitting Entity

____________________________________________________________ ______________

Signature		Date
Notarized By:
______________________________	____________________	____________________
Notary Public	County License Issued	License Number
Sworn to before me on: ________________________
Date
Mayor’s Office of Contract Services		2
253 Broadway, 9th Floor New York, NY 10007
Phone: 212 788 0018 Fax: 212 788 0049