Contracting Agency. If there are any material changes to programming or key staff please attach an explanation to this form. NOTE: If you have any questions about your prequalification status or the date of your last submission, please check the DYCD List of Prequalification Clearances at I , being duly sworn, state on behalf of the submitting organization that no material changes in programming or key staff have occurred since the last submission of the Prequalification/Recertification Application OR if material changes in programming or key staff have occurred since the last submission they are fully described on the attached pages. I understand that the City of New York will rely on the information supplied in this certification for discretionary funding purposes. Name of Nonprofit Organization (Vendor) Signature of Authorized Officer Vendor's Address Print Name / Title of Signer City / State / Zip Code Vendor's EIN Phone Number Email Address 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 0001 tel 212 788 0049 fax Conflict of Interest Disclosure and Compliance Certification A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THlS CERTlFICATION, AND/OR THE FAILURE TO CONDUCT APPROPRlATE DUE DILIGENCE IN VERIFYNG THE lNFORMATlON THAT IS THE SUBJECT MATTER OF THIS CERTIFICATION, MAY RESULT IN RENDERING THE VENDOR NON-RESPONSIBLE FOR THE PURPOSE OF CONTRACT AWARD, AND A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS CERTIFlCATlON MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRlMlNAL CHARGES. No Conflict of Interest: Except as otherwise fully disclosed below (attach additional pages as needed), the Vendor affirms, to the best of its knowledge, information and belief, that no City Elected Official, nor any person associated with any City Elected Official, is an employee, Director or Trustee, Officer or consultant to/of, or has any financial interest, direct or indirect, in the organization, or has received or will receive any financial benefit, directly or indirectly, from the organization or from this funding. For purposes of this certification, "associated”
Contracting Agency. If there are any material changes to programming or key staff please attach an explanation to this form. NOTE: If you have any questions about your prequalification status or the date of your last submission, please check the DYCD List of Prequalification Clearances at I , being duly sworn, state on behalf of the submitting organization that no material changes in programming or key staff have occurred since the last submission of the Prequalification/Recertification Application OR if material changes in programming or key staff have occurred since the last submission they are fully described on the attached pages. I understand that the City of New York will rely on the information supplied in this certification for discretionary funding purposes. Name of Nonprofit Organization (Vendor) Signature of Authorized Officer Vendor's Address Print Name / Title of Signer City / State / Zip Code Vendor's EIN Phone Number Email Address 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 0001 tel 212 788 0049 fax Conflict of Interest Disclosure and Compliance Certification A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THlS CERTlFICATION, AND/OR THE FAILURE TO CONDUCT APPROPRlATE DUE DILIGENCE IN VERIFYNG THE lNFORMATlON THAT IS THE SUBJECT MATTER OF THIS CERTIFICATION, MAY RESULT IN RENDERING THE VENDOR NON-RESPONSIBLE FOR THE PURPOSE OF CONTRACT AWARD, AND A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS CERTIFlCATlON MAY SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRlMlNAL CHARGES. No Conflict of Interest: Except as otherwise fully disclosed below (attach additional pages as needed), the Vendor affirms, to the best of its knowledge, information and belief, that no City Elected Official, nor any person associated with any City Elected Official, is an employee, Director or Trustee, Officer or consultant to/of, or has any financial interest, direct or indirect, in the organization, or has received or will receive any financial benefit, directly or indirectly, from the organization or from this funding. For purposes of this certification, "associated”
FY16_Over_100K_Single_Final_9-18-15.docx