New York Questionnaire Form – Fill Out and Use This PDF

The New York Questionnaire Form is a powerful tool that can help individuals establish accurate information on particular matters. This form may be of particular interest to those living in the state of New York, serving as a platform to provide in-depth answers regarding personal/business history, credit requests, and consumer data. Submitting this type of questionnaire allows for valuable records management needed to accurately address consumer inquiries or credit matters. By having an effective and comprehensive questionnaire, it provides an organized storage for up to date and reliable profiling for each situation.

New York Questionnaire Form PDF Details

Are you interested in living or doing business in New York City? If so, it’s important to understand the nuances of city life — and that starts by getting to know the diverse experiences, needs and opinions of those already established there. With this goal in mind, we've put together a comprehensive questionnaire form specifically designed for newcomers to gain insight into wide range of perspectives from current NYC inhabitants. Read on for more details about how our New York Questionnaire Form can give you an edge!

Question	Answer
Form Name	New York Questionnaire Form
Form Length	21 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 15 sec
Other names	vendor 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)

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
$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

DUNS number

none

National or regional stock exchange or NASDAQ listing

none

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

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?

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
a.	No	Yes
			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
c.	No	Yes
			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?

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
c.	No	Yes
			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?
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
9.	No		Yes
				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
10.	No	Yes
			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:

Yes

debarred from entering into any government contract?

Yes

found non-responsible on any government contract?

Yes

declared in default and/or terminated for cause?

Yes

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

Yes

suspended from bidding or entering into any government contract?

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
13.	No	Yes
			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
15.	No	Yes
			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
b.		No		Yes
					and/or business conduct in the past ten (10) years?
c.		No	Yes		have any felony, misdemeanor and/or administrative charges currently
c.		No	Yes
					pending?

17.		No	Yes		For the past five (5) years, has the submitting vendor or any of its
17.		No	Yes
					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
18.		No	Yes
					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
a.		No	Yes
					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?
b.		No	Yes
c.		No	Yes		pay any applicable federal, state or New York City taxes or other
c.		No	Yes
					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

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

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

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

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

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

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

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

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

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

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

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

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

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:

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

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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