Vendor Responsibility Form – Fill Out and Use This PDF

AC 3292-S (Rev. 9/13)

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

You have selected the For-Profit Construction questionnaire, commonly known as the “CCA-2,” which may be printed and completed in this format or, for your convenience, may be completed online using the New York State VendRep System.

COMPLETION & CERTIFICATION

The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or official must certify the questionnaire and the signature must be notarized.

NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID)

The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk at ITServiceDesk@osc.state.ny.us or call 866-370-4672.

DEFINITIONS

All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at http://www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf. These terms may not have their ordinary, common or traditional meanings. Each vendor is strongly encouraged to read the respective definitions for any and all underlined terms. By submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility Definitions List" existing at the time of certification.

RESPONSES

Every question must be answered. Each response must provide all relevant information which can be obtained within the limits of the law. However, information regarding a determination or finding made in error which was subsequently corrected or overturned, and/or was withdrawn by the issuing government entity, is not required. Individuals and Sole Proprietors may use a Social Security Number but are encouraged to obtain and use a federal Employer Identification Number (EIN).

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AC 3292-S (Rev. 9/13)NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

BUSINESS ENTITY INFORMATION

Legal Business Name		EIN
Address of the Principal Place of Business (street, city, state, zip code)		New York State Vendor Identification Number
		Telephone			Fax
				ext.
		Website
Authorized Contact for this Questionnaire
Name		Telephone			Fax
				ext.
Title		Email

Additional Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN used in the last five (5) years, the state or county where filed and the status (active or inactive).

Type	Name	EIN	State or County where filed	Status

I. BUSINESS CHARACTERISTICS

1.0Business Entity Type – Check appropriate box and provide additional information:

a)	Corporation (including PC)	Date of Incorporation
b)	Limited Liability Company	Date Organized
	(LLC or PLLC)
c)	Limited Liability Partnership	Date of Registration
d)	Limited Partnership	Date Established
e)	General Partnership	Date Established	County (if formed in NYS)
f)	Sole Proprietor	How many years in business?
g)	Other	Date Established

If Other, explain:

1.1 Was the Business Entity formed in New York State?			Yes	No
If “No,” indicate jurisdiction where the Business Entity was formed:
United States	State
Other	Country

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AC 3292-S (Rev. 9/13)NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

I. BUSINESS CHARACTERISTICS

1.2	Is the Legal Business Entity publicly traded?	Yes	No
If “Yes,” provide the CIK code or Ticker Symbol:
1.3	Is the Business Entity currently registered to do business in New York State?	Yes	No
	Note: Select “Not Required” if the Business Entity is a Sole Proprietor or General Partnership	Not Required
If “No,” explain why the Business Entity is not required to be registered to do business in New York State:
1.4	Is the responding Business Entity a Joint Venture? Note: If the submitting Business Entity is a Joint	Yes	No
	Venture, also submit a separate questionnaire for each Business Entity comprising the Joint Venture.
1.5	If the Business Entity’s Principal Place of Business is not in New York State, does the Business Entity	Yes	No
	maintain an office in New York State?	N/A
	(Select “N/A” if Principal Place of Business is in New York State.)
If “Yes,” provide the address and telephone number for one office located in New York State.
1.6	Is the Business Entity a New York State certified Minority-Owned Business Enterprise, or Women-Owned	Yes	No
	Business Enterprise, or New York State Small Business, or federally certified Disadvantaged Business
	Enterprise?
	If “Yes,” check all that apply:
	New York State certified Minority-Owned Business Enterprise (MBE)
	New York State certified Women-Owned Business Enterprise (WBE)
	New York State Small Business
	Federally certified Disadvantaged Business Enterprise (DBE)

1.7 Identify each person or business entity that is, or has been within the past five (5) years, Principal Owner of 5.0% or more of the firm’s shares; a Business Entity Official; or one of the five largest shareholders, if applicable. (Attach additional pages if necessary.)

Joint Ventures: Provide information for all firms involved.

Name (For each person, include	Title	Percentage of ownership	Employment status with
middle initial)		(Enter 0%, if not	the firm
		applicable)
			Current	Former
			Current	Former
			Current	Former
			Current	Former

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AC 3292-S (Rev. 9/13)NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

II. AFFILIATE and JOINT VENTURE RELATIONSHIPS

2.0 Are there any other construction-related firms in which, now or in the past five years, the submitting					Yes	No
Business Entity or any of the individuals or business entities listed in question 1.7 either owned or owns
5.0% or more of the shares of, or was or is one of the five largest shareholders or a director, officer, partner
or proprietor of said other firm? (Attach additional pages if necessary.)
Firm/Company Name	Firm/Company EIN		Firm/Company’s Primary Business
	(If available)		Activity
Firm/Company Address
Explain relationship with the firm and indicate percent of ownership, if applicable (enter N/A, if not applicable):
Are there any shareholders, directors, officers, owners, partners or proprietors that the submitting Business Entity					Yes	No
has in common with this firm?
Individual’s Name (Include middle initial)		Position/Title with Firm/Company
2.1 Does the Business Entity have any construction-related affiliates not identified in the response to question					Yes	No
2.0 above? (Attach additional pages if necessary.)
Affiliate Name	Affiliate EIN (If available)		Affiliate’s Primary Business Activity
Affiliate Address
Explain relationship with the affiliate and indicate percent of ownership, if applicable (enter N/A, if not applicable):
Are there any shareholders, directors, officers, owners, partners or proprietors that the submitting Business Entity					Yes	No
has in common with this affiliate?
Individual’s Name (Include middle initial)		Position/Title with Firm/Company
2.2 Has the Business Entity participated in any construction-related Joint Ventures within the past three (3)					Yes	No
years? (Attach additional pages if necessary.)
Joint Venture Name	Joint Venture EIN (If available)		Identify parties to the Joint Venture

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AC 3292-S (Rev. 9/13)NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

III. CONTRACT HISTORY

3.0	Has the Business Entity completed any construction contracts?	Yes	No
If “Yes,” list the ten most recent construction contracts the Business Entity has completed using Attachment A – Completed
Construction Contracts, found at www.osc.state.ny.us/vendrep/documents/questionnaire/ac3294s.doc.
If less than ten, include most recent subcontracts on projects up to that number.
3.1	Does the Business Entity currently have uncompleted construction contracts?	Yes	No

If “Yes,” list all current uncompleted construction contracts by using Attachment B – Uncompleted Construction Contracts, found at www.osc.state.ny.us/vendrep/documents/questionnaire/ac3295s.doc.

Note: Ongoing projects must be included.

IV. INTEGRITY – CONTRACT BIDDING

Within the past five (5) years, has the Business Entity, an affiliate, or any predecessor company or entity:

4.0	Been suspended or debarred from any government contracting process or been disqualified on any	Yes	No
	government procurement?
4.1	Been subject to a denial or revocation of a government prequalification?	Yes	No
4.2	Had any bid rejected by a government entity for lack of qualifications, responsibility or because of the	Yes	No
	submission of an informal, non-responsive or incomplete bid?
4.3	Had a proposed subcontract rejected by a government entity for lack of qualifications, responsibility or	Yes	No
	because of the submission of an informal, non-responsive or incomplete bid?
4.4	Had a low bid rejected on a government contract for failure to make good faith efforts on any Minority-	Yes	No
	Owned Business Enterprise, Women-Owned Business Enterprise or Disadvantaged Business Enterprise
	goal or statutory affirmative action requirements on a previously held contract?
4.5	Agreed to a voluntary exclusion from bidding/contracting with a government entity?	Yes	No
4.6	Initiated a request to withdraw a bid submitted to a government entity or made any claim of an error on a	Yes	No
	bid submitted to a government entity?

For each “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity involved, project(s), relevant dates, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer(s) below or attach additional sheets with numbered responses.

V. INTEGRITY – CONTRACT AWARD

Within the past five (5) years, has the Business Entity, an affiliate, or any predecessor company or entity:

5.0	Defaulted on or been suspended, cancelled or terminated for cause on any contract?	Yes	No
5.1	Been subject to an administrative proceeding or civil action seeking specific performance or restitution	Yes	No
	(except any disputed work proceeding) in connection with any government contract?
5.2	Entered into a formal monitoring agreement, consent decree or stipulation settlement as specified by, or	Yes	No
	agreed to with, any government entity?
5.3	Had its surety called upon to complete any contract whether government or private sector?	Yes	No
5.4	Forfeited all or part of a standby letter of credit in connection with any government contract?	Yes	No

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AC 3292-S (Rev. 9/13)

NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

V. INTEGRITY – CONTRACT AWARD

Within the past five (5) years, has the Business Entity, an affiliate, or any predecessor company or entity:

For each “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity/owners involved, project(s), contract number(s), relevant dates, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer(s) below or attach additional sheets with numbered responses.

VI. CERTIFICATIONS/LICENSES

Within the past five (5) years, has the Business Entity, an affiliate, or any predecessor company or entity:

6.0	Had a revocation or suspension of any business or professional permit and/or license?	Yes	No
6.1	Had a denial, decertification, revocation or forfeiture of New York State certification of Minority-Owned	Yes	No
	Business Enterprise, Women-Owned Business Enterprise or a federal certification of Disadvantaged
	Business Enterprise status, for other than a change of ownership?

For each “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity involved, relevant dates, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer(s) below or attach additional sheets with numbered responses.

VII. LEGAL PROCEEDINGS/GOVERNMENT INVESTIGATIONS

Within the past five (5) years, has the Business Entity, an affiliate, or any predecessor company or entity:

7.0 Been the subject of a criminal investigation, whether open or closed, or an indictment for any business-	Yes	No
related conduct constituting a crime under local, state or federal law?

7.1Been the subject of:

	(i.)	An indictment, grant of immunity, judgment or conviction (including entering into a plea bargain)	Yes	No
		for conduct constituting a crime; or
	(ii.)	Any criminal investigation, felony indictment or conviction concerning the formation of, or any	Yes	No
		business association with, an allegedly false or fraudulent Minority-Owned Business Enterprise,
		Women-Owned Business Enterprise, or a Disadvantaged Business Enterprise?
7.2	Received any OSHA citation, which resulted in a final determination classified as serious or willful?		Yes	No
7.3	Had a government entity find a willful prevailing wage or supplemental payment violation?		Yes	No
7.4	Had a New York State Labor Law violation deemed willful?		Yes	No
7.5	Entered into a consent order with the New York State Department of Environmental Conservation, or a		Yes	No
	federal, state or local government enforcement determination involving a violation of federal, state or local
	environmental laws?

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AC 3292-S (Rev. 9/13)

NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

VII. LEGAL PROCEEDINGS/GOVERNMENT INVESTIGATIONS

Within the past five (5) years, has the Business Entity, an affiliate, or any predecessor company or entity:

For each “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity involved, relevant dates, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer(s) below or attach additional sheets with numbered responses.

Note: Information regarding a determination or finding made in error, which was subsequently corrected or overturned, and/or was withdrawn by the issuing government entity, is not required.

VIII. LEADERSHIP INTEGRITY

If the Business Entity is a Joint Venture Entity, answer “N/A - Not Applicable” to questions in this section.

Within the past five (5) years has any individual previously identified or any individual currently or formerly having the authority to sign, execute or approve bids, proposals, contracts or supporting documentation on behalf of the Business Entity with any government entity been:

8.0	Sanctioned relative to any business or professional permit and/or license?		Yes	No
			N/A
8.1	Suspended, debarred or disqualified from any government contracting process?		Yes	No
			N/A
8.2	The subject of a criminal investigation, whether open or closed, or an indictment for any business-related		Yes	No
	conduct constituting a crime under local, state or federal law?		N/A
8.3	Charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or subject to a		Yes	No
	judgment for:		N/A
	(i.)	Any business-related activity, including but not limited to fraud, coercion, extortion, bribe or bribe-
		receiving, giving or accepting unlawful gratuities, immigration or tax fraud, racketeering, mail fraud,
		wire fraud, price-fixing or collusive bidding; or
	(ii.)	Any crime, whether or not business-related, the underlying conduct of which related to truthfulness,
		including but not limited to the filing of false documents or false sworn statements, perjury or
		larceny

For each “Yes,” provide an explanation of the issue(s), the individual involved, the relationship to the submitting Business Entity, the government entity involved, relevant dates, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer(s) below or attach additional sheets with numbered responses.

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AC 3292-S (Rev. 9/13)NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

IX. FINANCIAL AND ORGANIZATIONAL CAPACITY

9.0 Within the past five (5) years, has the Business Entity or any affiliate received any formal unsatisfactory	Yes	No
performance assessment(s) from any government entity on any contract?

If “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, the government entity involved, relevant dates, any remedial or corrective action(s) taken and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

9.1 Within the past five (5) years, has the Business Entity or any affiliate had any liquidated damages assessed	Yes	No
over $25,000?

If “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, relevant dates, the contracting party involved, the amount assessed and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

9.2 Within the past five (5) years, has the Business Entity or any affiliate had any liens, claims or judgments	Yes	No
over $25,000 filed against the Business Entity which remain undischarged or were unsatisfied for more
than 90 days? (Note: Including but not limited to tax warrants or liens. Do not include UCC filings.)

If “Yes,” provide an explanation of the issue(s), the Business Entity involved, the relationship to the submitting Business Entity, relevant dates, the Lien holder or Claimants’ name(s), the amount of the lien(s) and the current status of the issue(s). Provide answer below or attach additional sheets with numbered responses.

9.3 In the last seven (7) years, has the Business Entity or any affiliate initiated or been the subject of any	Yes	No
bankruptcy proceedings, whether or not closed, or is any bankruptcy proceeding pending?

If “Yes,” provide the Business Entity involved, the relationship to the submitting Business Entity, the bankruptcy chapter number, the court name and the docket number. Indicate the current status of the proceedings as “Initiated,” “Pending” or “Closed.” Provide answer below or attach additional sheets with numbered responses.

9.4	What is the Business Entity’s Bonding Capacity?
a. Single Project			b. Aggregate (All Projects)
9.5	List Business Entity’s Gross Sales for the previous three (3)
	Fiscal Years:
1st Year (Indicate year )		2nd Year (Indicate year )		3rd Year (Indicate year )
Gross Sales		Gross Sales		Gross Sales
9.6	List Business Entity’s Average Backlog for the previous three (3) fiscal years:
	(Estimated total value of uncompleted work on outstanding contracts)
1st Year (Indicate year )		2nd Year (Indicate year )		3rd Year (Indicate year )
Amount		Amount		Amount
9.7	Attach Business Entity’s most recent annual financial statement and accompanying notes or complete Attachment C – Financial
	Information, found at www.osc.state.ny.us/vendrep/documents/questionnaire/ac3296s.xls.

(This information must be attached.)

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AC 3292-S (Rev. 9/13)

NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

X. FREEDOM OF INFORMATION LAW (FOIL)

10.0 Indicate whether any information provided herein is believed to be exempt from disclosure under the	Yes	No
Freedom of Information Law (FOIL).

Note: A determination of whether such information is exempt from FOIL will be made at the time of any request for disclosure under FOIL. Attach additional pages if necessary.

If “Yes,” indicate the question number(s) and explain the basis for the claim.

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AC 3292-S (Rev. 9/13)

NYS VENDOR ID: 000000000

NEW YORK STATE VENDOR RESPONSIBILITY QUESTIONNAIRE

FOR-PROFIT CONSTRUCTION (CCA-2)

Certification

The undersigned: (1) recognizes that this questionnaire is submitted for the express purpose of assisting New York State government entities (including the Office of the State Comptroller (OSC)) in making responsibility determinations regarding award or approval of a contract or subcontract and that such government entities will rely on information disclosed in the questionnaire in making responsibility determinations; (2) acknowledges that the New York State government entities and OSC may, in their discretion, by means which they may choose, verify the truth and accuracy of all statements made herein; and (3) acknowledges that intentional submission of false or misleading information may result in criminal penalties under State and/or Federal Law, as well as a finding of non-responsibility, contract suspension or contract termination.

The undersigned certifies that he/she:

is knowledgeable about the submitting Business Entity’s business and operations;

has read and understands all of the questions contained in the questionnaire;

has not altered the content of the questionnaire in any manner;

has reviewed and/or supplied full and complete responses to each question;

to the best of his/her knowledge, information and belief, confirms that the Business Entity’s responses are true, accurate and complete, including all attachments, if applicable;

understands that New York State government entities will rely on the information disclosed in the questionnaire when entering into a contract with the Business Entity; and

is under an obligation to update the information provided herein to include any material changes to the Business Entity’s responses at the time of bid/proposal submission through the contract award notification, and may be required to update the information at the request of the New York State government entities or OSC prior to the award and/or approval of a contract, or during the term of the contract.

Signature of Owner/Official

Printed Name of Signatory

Title

Name of Business

Address

City, State, Zip

Sworn to before me this __________ day of _____________________________, 20___;

_____________________________________________ Notary Public

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