New York Questionnaire Form PDF Details

In a move to streamline the process of collecting data from vendors aiming to engage in business with New York City, the administration under Mayor Bill de Blasio and spearheaded by City Chief Procurement Officer Lisette Camilo introduced an updated version of the VENDEX questionnaires on September 25, 2014. These questionnaires now come in a fillable format though they must be completed, printed, and submitted in paper format. Comprising the Vendor and Principal Questionnaires alongside a Certification of No Change form, they serve as a critical tool for ensuring that the city only conducts business with responsibly vetted vendors, aligning with the mandate in the city’s charter. The meticulous design of these forms, while accommodating various data types, demonstrates a commitment to precision and security, particularly in handling sensitive information like social security numbers and employer identification numbers. Despite this digital shift, the insistence on paper submission underscores a cautious approach to data integrity and verification. This adaptation also reflects an ongoing pursuit of efficiency in the city’s procurement processes, while setting clear expectations for the vendor’s compliance and complete disclosure, crucial for maintaining transparency and trust in public and private sector interactions.

QuestionAnswer
Form NameNew York Questionnaire Form
Form Length21 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min 15 sec
Other namesvendor questionnaire page template, vendor questionnaire page, vendex information exchange system online, vendex exchange

Form Preview Example

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 0010 tel

212 788 0049 fax

September 25, 2014

Please note that effective, September 25, 2014, the VENDEX questionnaires are now fillable. YOU WILL STILL NEED TO COMPLETE, PRINT AND SUBMIT THE PAPER COPIES. These include the:

Vendor Questionnaire

Principal Questionnaire

Certification of No Change

Please be advised that certain fields require certain types of entry, e.g.:

Date fields require entries to match: MM/DD/YYYY

Telephone/Fax fields require entries to match: XXX-XXX-XXXX or (XXX) XXX-XXXX

EIN/TIN/SSN fields require 9 digits and no dashes

SSN only fields require entries to match XXX-XX-XXXX

Please also note that not all the fields will match the underlying formatting due to the limitations of the form, but ALL information will be able to be inputted. If you have any questions or concerns with the form, please email us at VENDEXFEEDBACK@cityhall.nyc.gov and we will get back to you as soon as possible.

PLEASE NOTE THAT ALTHOUGH THE FORMS ARE FILLABLE, YOU WILL STILL NEED TO

COMPLETE, PRINT AND SUBMIT THE PAPER COPIES.

Thank you for your kind consideration.

Printed on paper containing 30% post-consumer material.

Vendor Questionnaire FILLABLE 9/25/14

 

Revised 9/25/14

Page 1 of 20

Submitting vendor’s EIN/SSN/TIN

 

VENDOR QUESTIONNAIRE

The Vendor Information Exchange System (VENDEX) includes two questionnaires – the vendor questionnaire and the principal questionnaire. These have been developed to collect information from vendors who wish to do business with New York City, to ensure that New York City obeys the mandate in its charter to do business only with responsible vendors.

Questionnaires may be obtained in paper format from the VENDEX Unit (212-341-0933) or downloaded from the NYC website at http://www.nyc.gov/vendex.

Questionnaires must be completed in paper format. All questions must be answered. A response of “Not Applicable (N/A)”, or the equivalent, is not acceptable. Answers must be typewritten or printed in ink. If more space is needed to respond, photocopy the corresponding section’s page, check the box that additional information is attached, and attach the photocopied page to the questionnaire.

The publication “Vendor’s Guide to VENDEX” provides assistance and explanation for the questionnaires, including definitions of terms or phrases written in bold face throughout the questionnaires. If you have not obtained a copy of this publication, please download a copy from the New York City web site, or contact the VENDEX Unit at 212-341-0933. All forms must be sent to MOCS: 253 Broadway, 9th Floor; New York, New York 10007. If you have questions, contact the VENDEX Unit at 212-341-0933.

ANSWER THIS QUESTIONNAIRE CAREFULLY AND COMPLETELY. FAILURE TO SUBMIT A FULLY COMPLETED QUESTIONNAIRE MAY RESULT IN THE REJECTION OF THE VENDEX SUBMISSION. MAKING

ANY UNAUTHORIZED CHANGE OR ALTERATION TO THE

QUESTIONNAIRE WILL RENDER IT VOID.

Name of submitting vendor

 

 

 

Submitting Vendor’s EIN/ SSN/TIN: ____________________

 

Submitting vendor is

Prime

Parent

Controlling entity

Subcontractor

Type of submission: (Check one)

1.

2.

Full questionnaire

 

 

Changed questionnaire

 

 

If checked, provide submission date of last full questionnaire:

/

/

Name of person completing this vendor questionnaire

Employer/Title

Telephone Number (

 

)

 

-

 

Fax Number (

)

-

 

 

 

 

 

 

 

 

 

 

 

Email address

The disclosure of the social security number is mandatory under the right granted New York City by the Tax Reform Act of 1976 and will be used for the purpose of tax administration. The number may also be used for general identification purposes. If you do not consent to such additional use for general identification purposes, please check here

Vendor Questionnaire

 

Revised 9/25/14

Page 2 of 20

Submitting vendor’s EIN/SSN/TIN

 

1.Submitting vendor’s:

a.Principal executive office address

Street/P.O. Box

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

Telephone Number (

 

)

 

-

 

Fax Number (

 

)

 

-

 

b.Primary place of business (in the NYC metropolitan area)

Street/P.O. Box

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

Telephone Number (

 

)

 

-

 

Fax Number (

 

)

 

-

 

Check if the submitting vendor had other primary places of business in the NYC metropolitan area within the prior five (5) years and list information on page 7.

c.Primary place of business address is (check all that apply)

 

Owned

 

Rented

 

Rented with an option to buy

 

Donated

 

 

 

 

 

 

 

 

d.Addresses of the three largest sites at which it is anticipated that work would occur in connection with the contract pending at the times this questionnaire is completed, based on the number of people to be employed at each site:

 

 

address in 1a. (if applicable)

 

 

 

address in 1b. (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional site(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number (

 

)

 

 

-

 

 

Fax Number (

 

)

 

-

 

Check if submitting vendor’s three largest sites include other addresses and list information on page 7.

e.Web site address www.

f.Annual gross revenue (check range that applies)

 

 

$0 - $99,999

 

$100,000 - $499,999

 

 

 

$500,000 – $999,999

 

 

 

 

 

 

 

 

$1,000,000 - $ 2,499,999

 

$2,500,000 –$4,999,999

 

 

$5,000,000 or more

 

 

 

 

g.Business category (check all that apply)

 

 

 

Professional services

 

Manufacturing

 

Construction

 

 

 

Human Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commercial Services

 

Distribution

 

 

Retail

 

 

 

 

Not-for-Profit

 

Submitting vendor’s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h.

DUNS number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

none

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i.

National or regional stock exchange or NASDAQ listing

 

 

 

 

 

 

 

 

 

 

 

none

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

j.

Date submitting vendor began business in New York City

/

/

 

 

 

 

 

 

 

 

 

Check if additional information is attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a detailed response to all questions answered with information and/or “YES” in the question’s corresponding section starting on page 7 of this questionnaire.

 

Vendor Questionnaire

 

Revised 9/25/14

 

 

Page 3 of 20

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

No

 

 

Yes

Does the submitting vendor now use, or has it in the past ten (10) years

 

 

 

 

 

 

 

 

 

 

 

used, an EIN, TIN, SSN or DBA, trade name or abbreviation other than

 

 

 

 

 

 

 

 

 

 

 

the submitting vendor name or EIN/SSN/TIN number listed on page 1 of

 

 

 

 

 

 

 

 

 

 

 

this questionnaire?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

No

 

 

Yes

Has the submitting vendor used any other business addresses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and telephone numbers at any time during the prior five (5) years?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4a.

Date this business was formed ____ / ____ /____

State in which business was formed ________________________

County in which business was formed _______________________

Country in which business was formed (if not formed in USA) _____________________

Type of organization (check one):

_____ Business Corporation

_____ Not-for Profit Corporation

_____ Sole Proprietorship

_____ Partnership: ____ General ____ Limited _____ Limited Liability

_____ Limited Liability Company

_____ Joint Venture

_____ Other-indicate type: _____________________________________________

4b.

 

No

 

Yes

Are there any counties in New York State, other than the county listed

 

 

 

 

 

in response to question 4a, in which the submitting vendor has filed a

 

 

 

 

 

certificate of incorporation, a DBA, or the equivalent?

Provide a detailed response to all questions answered with information and/or “YES” in the question’s corresponding section starting on page 7 of this questionnaire.

Vendor Questionnaire

 

Revised 9/25/14

Page 4 of 20

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

a.

 

No

 

Yes

Does the submitting vendor share office space, staff, equipment, or

 

 

 

 

 

 

 

 

 

expenses with any other entities?

 

 

 

 

 

 

 

b.

 

 

No

 

Yes

Does the submitting vendor anticipate using or occupying any real

 

 

 

 

 

 

 

property, other than the business addresses listed in response to

 

 

 

 

 

 

 

Question 1 and 3, during the three (3) year VENDEX cycle?

c.

 

No

 

 

Yes

Does any principal owner or officer of the submitting vendor, or any

 

 

 

 

 

 

 

 

 

 

member of his/her immediate family, have an ownership interest in any

entity that holds the title or lease to any real property used by the submitting vendor in the New York City metropolitan area?

6.

a.Starting on page 8, list ALL of the submitting vendor’s principal owners and the three officers who exercise the most substantial degree of control over the submitting vendor.

b.

 

No

 

Yes

Pursuant to any stock option or any other arrangements, does any

 

 

 

 

 

individual or entity have the right within the next three (3) years to

 

 

 

 

 

acquire stock in the submitting vendor, which, when combined with

 

 

 

 

 

current holdings, would make such an individual or entity a principal

 

 

 

 

 

owner or officer?

c.

 

No

 

Yes

Is ten (10) percent or more of the submitting vendor’s stock or

 

 

 

 

 

 

 

ownership currently used or pledged as collateral for any loan or

 

 

 

 

 

obligation?

7.Are there any individuals now serving in a managerial or consulting capacity to the submitting vendor, whether or not as a principal owner or officer, who now serve, or within the past five (5) years have served as:

a.

 

 

No

 

Yes

an elected or appointed public official or officer?

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

 

No

 

Yes

a full or part-time employee in a New York City agency or as a

 

 

 

 

 

 

 

 

 

 

consultant to any New York City agency?

 

 

 

 

 

 

 

 

 

c.

 

 

 

No

 

Yes

an officer of any political party organization in New York City, whether

 

 

 

 

 

 

 

 

 

 

paid or unpaid?

 

 

 

 

 

 

 

 

d.

 

 

No

 

Yes

as a consultant or advisor to a New York City agency performing

 

 

 

 

 

 

 

 

 

 

services related to the solicitation, negotiation, operation and/or

 

 

 

 

 

 

 

 

 

 

administration of contracts on which the submitting vendor will work

 

 

 

 

 

 

 

 

 

 

during this three (3) year VENDEX cycle?

 

 

 

 

 

 

 

 

 

 

 

8.

 

 

 

 

 

No

 

Yes

Does the submitting vendor control one or more entities?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

 

 

 

 

 

No

 

Yes

Does the submitting vendor have one or more affiliates, and/or is it a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

subsidiary of, and controlled by any other entity?

Provide a detailed response to all questions answered with information and/or “YES” in the question’s corresponding section starting on page 7 of this questionnaire.

Vendor Questionnaire

 

Revised 9/25/14

Page 5 of 20

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

10.

 

No

 

Yes

Has the submitting vendor, or any affiliate listed in response to

 

 

 

 

 

 

 

Question 9, been a subcontractor on any contract with any New York

 

 

 

 

 

City agency in the past three (3) years?

11.At any time during the past five (5) years, has the submitting vendor or any of its affiliates, been subject to any of the following actions, whether pending or completed:

a.

 

No

 

 

 

Yes

debarred from entering into any government contract?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

 

 

 

 

 

No

 

 

 

 

 

Yes

found non-responsible on any government contract?

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

 

 

 

No

 

 

 

Yes

declared in default and/or terminated for cause?

 

 

 

 

 

 

 

 

 

 

 

d.

 

 

No

 

 

 

Yes

determined to be ineligible to bid or propose on any contract?

e.

 

No

 

 

Yes

suspended from bidding or entering into any government contract?

 

 

 

 

 

 

 

 

 

 

f.

 

 

No

 

 

Yes

received an overall unsatisfactory performance rating from any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

government agency on any contract?

12.Are there or have there been any judgments, injunctions, or liens, including, but not limited to, judgments based on taxes owed, fines and penalties assessed by any government agency, elected official, or the New York City Council initiated against the submitting vendor and/or any affiliate:

a.

 

No

 

Yes

at any time within the past five (5) years?

 

 

 

 

 

 

 

 

 

b.

 

 

No

 

 

 

Yes

that remain open, unsatisfied, or in effect today?

 

 

 

 

 

 

 

 

 

13.

 

 

No

 

 

Yes

Have any bankruptcy proceedings been initiated by or against the

 

 

 

 

 

 

 

 

 

 

 

 

submitting vendor or its affiliates within the past seven (7) years (whether

 

 

 

 

 

 

 

 

or not closed) or is any bankruptcy proceeding pending by or against the

 

 

 

 

 

 

 

 

submitting vendor or its affiliates regardless of date of filing?

14.In the past five (5) years, has the submitting vendor, any of its principal owners or officers, or any affiliate:

a.

 

No

 

Yes

had any permit, license, concession, franchise or lease terminated for

 

 

 

 

 

 

 

 

cause or revoked?

 

 

 

 

 

 

 

 

b.

 

 

No

 

 

 

Yes

been disqualified for cause as a bidder on any permit, license,

 

 

 

 

 

 

 

 

concession, franchise or lease?

 

 

 

 

 

 

 

 

 

15.

 

 

No

 

 

Yes

In the past five (5) years, have any of the submitting vendors or any of

 

 

 

 

 

 

 

 

 

 

 

 

the submitting vendors’ affiliates or any individual currently or within

 

 

 

 

 

 

 

 

that period serving as a principal owner, officer or managerial

 

 

 

 

 

 

 

 

employee been investigated by any government agency, including,

 

 

 

 

 

 

 

 

but not limited to, federal, state and local regulatory agencies?

Provide a detailed response to all questions answered with information and/or “YES” in the question’s corresponding section starting on page 7 of this questionnaire.

Vendor Questionnaire

 

Revised 9/25/14

Page 6 of 20

Submitting vendor’s EIN/SSN/TIN

 

16.Has the submitting vendor, any affiliate, or any of their current or former principal owners or officers or managerial employees:

a.

 

No

 

Yes

been convicted of a misdemeanor and/or found in violation of any

 

 

 

 

 

 

 

 

administrative, statutory, or regulatory provisions in the past five (5)

 

 

 

 

 

 

 

 

years?

b.

 

No

 

 

Yes

been convicted of a felony, and/or any crime related to truthfulness

 

 

 

 

 

 

 

 

 

 

 

and/or business conduct in the past ten (10) years?

c.

 

No

 

Yes

have any felony, misdemeanor and/or administrative charges currently

 

 

 

 

 

 

 

 

 

 

pending?

 

 

 

 

 

 

 

 

 

17.

 

 

No

 

Yes

For the past five (5) years, has the submitting vendor or any of its

 

 

 

 

 

 

 

 

 

 

 

principal owners, officers, or any affiliate had any sanction imposed

 

 

 

 

 

 

 

 

as a result of judicial or administrative disciplinary proceedings with

 

 

 

 

 

 

 

 

respect to any professional license held?

 

 

 

 

 

 

 

 

 

18.

 

 

No

 

 

Yes

Other than the submitting vendor’s employees, did the submitting

 

 

 

 

 

 

 

 

 

 

 

 

vendor retain, employ or designate anyone to influence the preparation

 

 

 

 

 

 

 

 

of contract specifications, or the solicitation or award of any contract

 

 

 

 

 

 

 

 

during this three (3) year VENDEX cycle?

 

 

 

 

 

 

 

 

 

19.

 

 

 

 

 

 

 

 

a.

 

No

 

Yes

Is the submitting vendor exempt from income taxes under the Internal

 

 

 

 

 

 

 

 

 

 

Revenue Code?

 

 

During the past five (5) years, has the submitting vendor failed to:

b.

 

No

 

Yes

file any applicable federal, state or New York City tax returns?

 

 

c.

 

No

 

Yes

pay any applicable federal, state or New York City taxes or other

 

 

 

 

 

 

 

 

 

 

assessed New York City charges, including but not limited to water and

 

 

 

 

 

 

 

 

sewer charges?

 

 

 

 

 

 

 

 

 

This question applies to not-for-profit vendors, others please answer “no”.

20. No Yes If the submitting vendor is a not-for-profit corporation, in the past three (3) years, have any audits of the submitting vendor revealed material weaknesses in its system of internal controls, compliance with contractual agreements and/or laws and regulations?

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

Revised 9/25/14

Page 7 of 20

Submitting vendor’s EIN/SSN/TIN

 

Provide details to questions answered “yes” in the corresponding section below.

Corresponds to Question 1.

1b. Submitting vendor’s other primary place(s) of business

Street/P.O. Box

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

Telephone Number (

 

)

 

-

 

Fax Number (

 

)

 

-

 

1d. Submitting vendor’s largest sites

Street/P.O. Box

 

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

(

 

)

 

-

 

Fax Number (

 

)

 

-

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

(

 

)

 

-

 

Fax Number (

 

)

 

-

 

Check if attaching additional information

Corresponds to Question 2.

Other DBA, name, trade name, abbreviation

Other EIN/TIN/SSN

 

 

 

 

 

Dates in use - from

/

/

to

/

/

Still in use

Check if attaching additional information

Corresponds to Question 3.

Other business addresses and telephone numbers in the last five (5) years

(Check One)

Current

Former

Street/P.O. Box

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Main telephone number (

 

)

 

-

 

Main fax number (

 

)

 

-

 

 

Check if attaching additional information

Corresponds to Question 4. (check all that apply)

4b.

Certificate of incorporation Other, please identify

DBA

County

 

 

Date

 

/

 

/

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

Revised 9/25/14

Page 8 of 20

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 5. (check all that apply)

 

 

 

 

 

 

 

5a. Item(s) shared

 

Space

 

Staff

 

 

Equipment

 

Expenses

 

 

 

 

 

Other entity’s name ___________________________________________________

Other entity’s EIN/TIN/SSN __________________________

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

Floor #/Suite #

City/State/Zip Code

Check if attaching additional information

5b. Address

Street/P.O. Box

Floor #/Suite #

City/State/Zip Code

Additional addresses to be used not yet known

Check if attaching additional information

5c. Ownership interest is

 

principal owner

officer

immediate family

Name of party with ownership interest

Name of entity holding title or lease

Check if attaching additional information

Corresponds to Question 6.

 

 

 

 

6a.

Principal owner’s name

 

 

 

 

 

EIN/SSN

Date of birth

/

/

Percent of ownership

 

individual

partnership

joint venture

 

corporation

 

Principal owner’s name

 

 

 

 

 

EIN/SSN

Date of birth

/

/

Percent of ownership

 

individual

partnership

joint venture

 

corporation

 

Principal owner’s name

 

 

 

 

 

EIN/SSN

Date of birth

/

/

Percent of ownership

 

individual

partnership

joint venture

 

corporation

 

Check if attaching additional information

 

 

 

 

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

 

 

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

 

Page 9 of 20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 6 continued.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6a.

Officer’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cont. SSN

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

Date of birth

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Officer’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

Date of birth

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Officer’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

Date of birth

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6b.

 

 

 

Individual

 

 

 

 

 

Entity

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If individual, date of birth

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stock option

 

 

Other (explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Percent of ownership:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If entity is checked, is the business address the same as that listed in question 1?

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If no, list address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Floor #/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Main telephone number (

 

 

)

 

 

 

 

-

 

 

Main fax number (

 

)

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6c.

 

(Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stock

Ownership:

Used Loan

Pledged as collateral Obligation

Other (explain)

Name of receiving individual and/or entity ___________________________________

EIN/SSN

 

If individual, date of birth

/

/

 

 

 

 

 

 

 

 

 

 

 

Percent of ownership:

 

 

Transaction date

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

 

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

 

Page 10 of 20

 

 

 

 

 

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 7. (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7a.

 

 

 

elected official

 

 

elected officer

 

 

 

 

appointed official

 

 

 

 

 

 

appointed officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

principal owner or officer

 

 

 

 

 

managerial capacity

 

 

 

consulting capacity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

 

 

 

Date of Birth

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title in submitting vendor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of organization elected or appointed to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7b.

 

 

Full-time NYC agency employee

 

 

 

Part-time NYC agencyemployee

 

Consultant toNYCagency

 

 

 

 

 

 

 

 

 

principal owner or officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

managerial capacity

 

 

 

 

consulting capacity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

 

 

 

Date of Birth

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title in submitting vendor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of NYC agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual serves/served New York City agency as

 

 

 

consultant

 

 

 

 

 

 

advisor

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7c.

 

 

 

Paid officer in NYC political party

 

 

Unpaid officer in NYC political party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

principal owner or officer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

managerial capacity

 

 

 

 

consulting capacity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

 

 

 

Date of Birth

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title in submitting vendor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of political party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7d. Individual serves submitting vendor as

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

principal owner or officer

 

 

 

 

 

managerial capacity

 

consulting capacity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Individual serves/served New York City agency as

 

 

consultant

 

 

 

 

 

advisor

 

 

 

 

 

 

 

Employee’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

 

 

 

Date of Birth

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title in submitting vendor

Name of NYC agency

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

 

 

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

Page 11 of 20

 

 

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 8. (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of controlled entity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For profit

 

Not-for-profit corporation

 

 

Other (explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Main telephone number (

 

 

)

 

 

 

-

 

 

 

Main fax number (

 

)

 

 

-

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 9. (Check all that apply)

Submitting vendor has one or more affiliate(s)

(If checked) Name of affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of business

 

For profit

 

 

 

 

Not-for-profit corporation

 

 

Other (explain)

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Main telephone number (

 

)

 

 

 

-

 

Main fax number (

 

)

 

 

-

 

 

 

Check if attaching additional information

Submitting vendor is a subsidiary of:

Submitting vendor is controlled by:

(If checked) Name of entity

 

 

 

 

 

 

 

 

 

 

 

__________

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of business

 

For profit

 

Not-for-profit corporation

 

Other (explain)

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Main telephone number (

 

 

)

 

 

-

 

Main fax number (

 

)

 

-

 

 

 

 

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

 

 

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

Page 12 of 20

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 10.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

submitting vendor

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

Name of prime contractor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contract type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contract number

 

 

 

 

Contract start date

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Subcontract amount $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of NYC agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 11.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11a.

 

 

submitting vendor

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Debarment proceeding pending

 

 

Debarment in effect

 

 

 

Period of debarment completed

 

 

 

 

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of finding (if any) / /

Name of government agency

Address

Street/P.O. Box

City/State/Zip Code

Check if attaching additional information

11b.

 

 

submitting vendor

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

Date notified of non-responsible finding

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitting vendor/affiliate appealed the finding of non-responsible, with the following

 

outcome(s)

 

 

upheld

 

 

reversed

 

 

 

 

 

pending

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of finding (if any)

 

/

/

 

 

 

 

 

 

Name of government agency

Address

Street/P.O. Box

City/State/Zip Code

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

 

 

 

 

Revised 9/25/14

 

 

 

Page 13 of 20

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 11 continued.

 

 

 

 

 

 

 

 

 

 

11c.

 

 

submitting vendor

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Declared in default

 

 

 

Terminated for cause

 

 

 

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of finding (if any)

 

 

/

 

/

 

 

proceeding ongoing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of government agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11d.

 

 

 

submitting vendor

 

 

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ineligible to bid

 

Ineligible to propose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of finding (if any)

 

/

 

 

/

 

 

 

 

 

proceeding ongoing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of government agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11e.

 

 

submitting vendor

 

 

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suspension is

 

 

pending

 

 

 

in effect

 

 

 

completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of finding (if any)

/

/

 

 

proceeding ongoing

 

 

 

 

 

 

 

 

 

Name of government agency

Address

Street/P.O. Box

City/State/Zip Code

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

 

 

 

Revised 9/25/14

 

 

 

Page 14 of 20

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 11 continued.

 

 

 

 

 

 

 

 

 

11f.

 

 

submitting vendor

 

affiliate

 

 

 

 

If affiliate, name

 

 

 

EIN/TIN/SSN

 

 

 

 

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of finding (if any)

 

/

/

 

 

proceeding ongoing

 

 

 

 

 

 

 

 

 

 

Name of government agency

Address

Street/P.O. Box

City/State/Zip Code

Check if attaching additional information

 

Corresponds to Question 12. (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12a.

 

 

submitting vendor

 

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

judgment

 

 

injunction

 

 

lien

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other (explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date obligation filed

 

 

/

/

 

 

 

Date discharged

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount of original obligation $

 

 

Amount outstanding $

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12b.

 

 

submitting vendor

 

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

judgment

 

 

injunction

 

lien

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other (explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

open

 

unsatisfied

 

in effect today

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount of original obligation $

 

 

Amount outstanding $

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

 

 

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

 

 

 

 

Page 15 of 20

 

 

 

 

 

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 13. (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Within the past seven (7) years, bankruptcy proceedings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

have been initiated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

have been closed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

remain pending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

These proceedings involve

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

submitting vendor

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If affiliate, name

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Court name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Court address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Docket number

 

 

 

 

 

 

 

 

 

Date initiated __________Date closed ___/__/___

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 14. (Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14a.

 

 

 

submitting vendor

 

 

principal owners or officers

 

 

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

terminated for cause

 

 

revoked

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

permit

 

 

 

license

 

 

concession

 

 

franchise

 

 

 

 

 

lease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of sanctioning agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify reason(s) for action

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14b.

 

 

 

submitting vendor

 

 

 

principal owners or officers

 

 

 

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

disqualified for cause

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

/

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

permit

 

 

license

 

 

lease

 

concession

 

 

 

 

franchise

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of sanctioning agency

Specify the reason(s) for action

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

Page 16 of 20

 

 

 

 

 

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 15.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

submitting vendor

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

individual serving as

 

 

principal owner

 

 

 

officer

 

 

 

 

managerial employee

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

 

Name of investigating government agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date initiated

 

/

 

 

/

 

 

Date completed

/

 

/

 

 

 

 

ongoing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of investigation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

Corresponds to Question 16. (Check all that apply)

 

 

 

 

 

 

16a.

 

submitting vendor

 

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

former

 

principal owner

 

officer

 

 

managerial employee

 

 

 

 

 

 

 

 

 

 

 

 

current

 

principal owner

 

officer

 

 

managerial employee

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

Found in violation of

 

 

 

administrative provision(s)

 

 

 

 

 

 

 

 

 

 

 

 

statutory provisions(s) regulatory provision(s)

convicted of a misdemeanor Summary of finding

Date of action

 

/

/

Charging agency_________________________

 

 

 

 

 

 

 

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

 

 

 

 

Revised 9/25/14

 

 

 

Page 17 of 20

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 16 continued.

 

 

 

 

 

 

 

 

 

16b.

 

 

submitting vendor

 

affiliate

 

 

 

 

 

 

former principal owners or officers or managerial employees

 

 

 

 

 

 

 

 

 

 

 

 

current principal owners or officers or managerial employees

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

convicted of a felony in the past ten (10) years

 

 

 

 

 

 

 

 

 

 

 

 

convicted of a crime related to truthfulness in the past ten (10) years

 

 

 

 

 

 

 

 

 

 

 

 

onvicted a crime related to business conduct in the past ten (10) years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of felony and/or crime

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of action

 

/

 

/

 

 

Charging agency

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16c.

 

 

submitting vendor

 

 

affiliate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

former principal owners or officers or managerial employees

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

current principal owners or officers or managerial employees

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

Charges pending are

 

 

felony

 

misdemeanor

 

 

administrative charges

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of finding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of action

 

/

/

 

Charging agency

 

 

 

 

 

 

 

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

Revised 9/25/14

Page 18 of 20

Submitting vendor’s EIN/SSN/TIN

 

Corresponds to Question 17. Name of sanctioning agency

Name of sanctioned individual or entity __________________________________

 

submitting vendor

 

principal owners or officers

 

affiliate

EIN/SSN/TIN

judicial disciplinary proceedings with respect to any professional license held administrative disciplinary proceedings with respect to any professional license held

Summary

Date of action

 

/

/

 

 

 

 

 

 

Check if attaching additional information

Corresponds to Question 18.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

EIN/TIN/SSN

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street/P.O. Box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number (

 

)

 

-

 

Fax number (

 

)

 

 

-

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 19.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19a. Reason for exemption from income taxes

Check if attaching additional information

19b. Submitting vendor failed to file:

 

Federal taxes

 

 

State taxes

 

 

NYC taxes

 

 

 

Other

 

 

 

 

 

 

If “State” is checked, and other than N.Y., name State

 

 

 

 

 

 

 

 

 

 

 

If “Other“ is checked, specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Taxes were not filed for tax years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

20

 

 

 

 

 

20

 

 

 

20

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

 

 

Vendor Questionnaire

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Revised 9/25/14

 

 

 

 

 

Page 19 of 20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitting vendor’s EIN/SSN/TIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question 19 continued.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19c. Submitting vendor failed to pay:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal taxes

 

 

 

 

State taxes

 

 

NYC taxes

 

 

Other NYC charges

 

 

 

 

 

 

 

If “State” is checked, and other than N.Y., name State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If “Other NYC charges“ is checked, specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Taxes were not paid for tax years:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

20

 

 

 

 

20

 

 

 

20

 

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Corresponds to Question 20.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

audits revealed material weaknesses in:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

system of internal controls

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

compliance with contractual agreements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

compliance with laws and regulations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if attaching additional information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide a detailed response to all questions checked “YES” from pages one–six. If you need more space to respond, photocopy the corresponding section’s pages, check the box that additional information is attached, and attach the photocopied page to this questionnaire.

Vendor Questionnaire

 

Revised 9/25/14

Page 20 of 20

Submitting vendor’s EIN/SSN/TIN

 

CERTIFICATION

A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS QUESTIONNAIRE MAY RESULT IN RENDERING THE SUBMITTING VENDOR NON-RESPONSIBLE WITH RESPECT TO THE VENDEX SUBMISSION, AND, IN ADDITION, MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRIMINAL CHARGES.

I,

 

 

serving as

 

for

 

,

 

 

 

 

 

 

 

 

 

 

Name

Title

Submitting Vendor’s Name

I hereby certify that:

I have not altered the substance of this questionnaire in any manner;

I have read and understand all of the items contained in the foregoing 19 pages of this questionnaire and

the following

 

pages of attachments;

I have supplied full and complete responses to each item therein to the best of my knowledge, information and belief;

I understand that the New York City will rely on the information supplied in this questionnaire as an inducement to enter into a contract with the submitting vendor;

I understand that at the time of execution of any contract with New York City, the submitting vendor will be required to certify that the information I have supplied remains accurate, and I further understand that I may provide to the VENDEX unit, in writing, any change(s) in the information provided in this questionnaire at the time of any change in the circumstances;

I will notify the VENDEX unit in writing of all subcontractors engaged pursuant to each resulting contract valued at one hundred thousand dollars ($100,000) or more;

The submitting vendor was not founded or established and is not operated in a manner to evade the application or defeat the purpose of Section 6-116.2, subdivision (b) of the New York City Administrative Code, and is not the successor, assignee or affiliate of an entity which is ineligible to bid or propose on contracts or against which a proceeding to determine eligibility to bid or propose on contracts or against which a proceeding to determine eligibility to bid or propose on contracts is pending.

I further certify as to the following ongoing obligations of the submitting vendor:

The New York City Administrative Code provides that the submitting vendor shall update the information provided in this questionnaire by submitting a current questionnaire every three years, to be provided no later than the date of award of any contract subsequent to the expiration of the three year period;

The submitting vendor is required to certify, at the time of any future award, that the information previously submitted in its most recent VENDEX submission is full, complete and accurate, except as to any changed information the submitting vendor provides at that time and, as to that information, the submitting vendor shall be required to certify that it is full, complete and accurate.

Sworn to before me this

 

day of

 

, 20

 

;

Notary Public

Print name

Signature

/ /

Date

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