Subcontractors with subcontract annual value of more than $50,000 must complete This step must be completed for each person disclosed in Step 2, Option A and Step 3, and for each entity and sole proprietor disclosed in Step 1. Please provide the name of the person or entity for which responses are provided: Within the previous ten have you had debarment from contracting with any governmental Yes No entity? Within the previous ten years, have you had any professional licensure discipline? Yes No Within the previous ten years, have you had any bankruptcies? Yes No Within the previous ten have you had any adverse civil judgments and administrative findings? Yes No Within the previous ten years, have you had any criminal felony convictions? Yes No If you answered please provide a detailed explanation that includes, but is not limited to the name, State agency or university, “Yes”, and position title of each individual and descriptive information regarding the nature of the debarment and/or legal proceeding. Step 8 Disclosure of Current and Pending Contracts Complete only if bid, or contract has an annual value over $25,000 Subcontractors with subcontract annual value of more than $50,000 must complete If you selected Option 1, 2, 3, 4 or 6 in Step 1, do you have any contracts, pending contracts, bids, proposals, or other ongoing procurement relationships with State of Illinois agencies or universities? Yes No If please specify Attach an additional page in the same format as provided below, if desired. “Yes”, Agency/University Project Title Status Value Contract Reference/P.O./ Bulletin # Please explain the procurement relationship: Step 9 Sign the Disclosure All vendors must complete regardless of annual bid, offer, or contract value Subcontractors with subcontract annual value of more than $50,000 must complete This disclosure is signed and made under penalty of perjury by an authorized officer or employee on behalf of the Offeror pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code. This disclosure information is submitted on behalf of: Name of Disclosing Entity:
Subcontractors with subcontract annual value of more than $50,000 must complete This step must be completed for each person disclosed in Step 2, Option A and Step 3, and for each entity and sole proprietor disclosed in Step 1. Please provide the name of the person or entity for which responses are provided: Within the previous ten have you had debarment from contracting with any governmental entity? Yes No Within the previous ten years, have you had any professional licensure discipline? Yes No Within the previous ten years, have you had any bankruptcies? Yes No Within the previous ten have you had any adverse civil judgments and administrative findings? Yes No Within the previous ten years, have you had any criminal felony convictions? Yes No If you answered “Yes”, please provide a detailed explanation that includes, but is not limited to the name, State agency or university, and position title of each individual and descriptive information regarding the nature of the debarment and/or legal proceeding. Step 8 Disclosure of Current and Pending Contracts Complete only if bid, or contract has an annual value over $25,000 Subcontractors with subcontract annual value of more than $50,000 must complete If you selected Option 1, 2, 3, 4 or 6 in Step 1, do you have any contracts, pending contracts, bids, proposals, or other ongoing procurement relationships with State of Illinois agencies or universities? Yes No If “Yes”, please specify Attach an additional page in the same format as provided below, if desired. Agency/University Project Title Status Value Contract Reference/P.O./ Bulletin # Please explain the procurement relationship: Step 9 Sign the Disclosure All vendors must complete regardless of annual bid, offer, or contract value Subcontractors with subcontract annual value of more than $50,000 must complete This disclosure is signed and made under penalty of perjury by an authorized officer or employee on behalf of the Offeror pursuant to Sections 50-13 and 50-35 of the Illinois Procurement Code. This disclosure information is submitted on behalf of: Name of Disclosing Entity:
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