Opm Ethics Form 5 – Fill Out and Use This PDF

OPM Et hics For m 5

Rev . 10 - 31 - 07

STATE OF CONNECTICUT

CONSULTING AGREEMENT AFFIDAVIT

Affidavit to accompany a State contract for the purchase of goods and services with a value of $50,000 or more in a calendar or fiscal year, pursuant to Connecticut General Statutes §§ 4a- 81(a) and 4a-81(b)

I N STRUCTI ON S:

I f t h e bidde r or v e n dor h a s e n t e r e d in t o a con su lt in g a gr e e m e n t , a s de fin e d by Con n e ct icu t

Ge n e r a l St a t u t e s § 4 a - 8 1 ( b) ( 1 ) : Com plet e all sect ions of t he for m . I f t he bidder or vendor has ent er ed int o m or e t han one such consult ing agr eem ent , use a separ at e for m for each agr eem ent . Sign and dat e t he

for m in t he pr esence of a Com m issioner of t he Super ior Cour t or Not ar y Public.	I f t h e bidde r or v e n dor
h a s n ot e n t e r e d in t o a con su lt in g a gr e e m e n t , a s de fin e d by Con n e ct icu t	Ge n e r a l St a t u t e s § 4 a -

8 1 ( b) ( 1 ) : Com plet e only t he shaded sect ion of t he for m . Sign and dat e t he for m in t he pr esence of a Com m issioner of t he Super ior Cour t or Not ar y Public.

Subm it com plet ed for m t o t he aw ar ding St at e agency w it h bid or pr oposal. For a sole sour ce aw ar d, subm it com plet ed for m t o t he aw ar ding St at e agency at t he t im e of cont r act execut ion .

This affidav it	m ust be am ended if t he cont r act or ent er s int o any new consult ing agr eem ent ( s) dur ing t he
t er m of t he St at e cont r act .
AFFI D AV I T:	[ Num ber of Affidav it s Sw or n and Subscr ibed On This Day : _____ ]

I , t he under signed, her eby sw ear t hat I am t he chief official of t he bidder or v endor aw ar ded a cont r act , as descr ibed in Connect icut Gener al St at ut es § 4a- 81( a) , or t hat I am t he indiv idual aw ar ded such a cont r act w ho is aut hor ized t o execut e such cont r act . I fur t her sw ear t hat I hav e not ent er ed int o any consult ing agr eem ent in connect ion w it h such cont r act , e x ce pt for t h e a gr e e m e n t list e d be low :

__________________________________________		_______________________________________
Consult ant ’s Nam e and Tit le		Nam e of Fir m ( if applicable)
__________________	___________________	___________________
St ar t Dat e	End Dat e	Cost

Descr ipt ion of Ser v ices Pr ovided: ___________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

I s t he consult ant a for m er St at e em ployee or for m er public official?		YES	NO
I f YES: ___________________________________	__________________________
Nam e of For m er St at e Agency	Ter m inat ion Dat e of Em ploym ent

Sw or n as t r ue t o t he best of m y k nowledge and belief, subj ect t o t he penalt ies of false st at em ent .

___________________________	___________________________________	__________________
Pr int ed Nam e of Bidder or Vendor	Sign a t u r e of Ch ie f Officia l or I n dividu a l	D a t e
	___________________________________	___________________
	Pr int ed Nam e ( of abov e)	Aw ar ding St at e Agency

Sw or n a n d su bscr ibe d be for e m e on t h is _ _ _ _ _ _ _ da y of _ _ _ _ _ _ _ _ _ _ _ _ , 2 0 0 _ _ .

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Com m ission e r of t h e Su pe r ior Cou r t or N ot a r y Pu blic