RFP for Leased Office Space

IRANIAN ENERGY SECTOR DIVESTMENT
Contractor/Proposer hereby represents that said Contractor/Proposer is in compliance with New
York State General Municipal Law Section 103-g entitled "Iranian Energy Sector Divestment", in
that said Contractor/Proposer has not:
a) Provided goods or services of $20 Million or more in the energy sector of Iran including but not
limited to the provision of oil or liquefied natural gas tankers or products used to construct or
maintain pipelines used to transport oil or liquefied natural gas for the energy sector of Iran; or
b) Acted as a financial institution and extended $20 Million or more in credit to another person for
forty-five days or more, if that person's intent was to use the credit to provide goods or services in
the energy sector in Iran.
Any Contractor/Proposer who has undertaken any of the above and is identified on a list created
pursuant to Section 165-a (3)(b) of the New York State Finance Law as a person engaging in
investment activities in Iran, shall not be deemed a responsible bidder pursuant to Section 103 of
the New York State General Municipal Law.
Except as otherwise specifically provided herein, every Contractor/Proposer submitting a
bid/proposal in response to this Request for Bids/Request for Proposals must certify and affirm the
following under penalties of perjury:
a) "By submission of this bid, each bidder and each person signing on behalf of any bidder certifies,
and in the case of a joint bid, each party thereto certifies as to its own organization, under penalty
of perjury, that to the best of its knowledge and belief, that each bidder is not on the list created
pursuant to NYS Finance Law Section 165-a (3)(b)."
This statement will be accepted electronically in accordance with the provisions of Section 103 of
the General Municipal Law.
Except as otherwise specifically provided herein, any Bid/Proposal that is submitted without having
complied with subdivision (a) above, shall not be considered for award. In any case where the
Bidder/Proposer cannot make the certification as set forth in subdivision (a) above, the
Bidder/Proposer shall so state and shall furnish with the bid a signed statement setting forth in detail
the reasons therefore. The County reserves its rights, in accordance with General Municipal Law
Section 103-g to award the Bid/Proposal to any Bidder/Proposer who cannot make the certification,
on a case-by-case basis under the following circumstances:
1 The investment activities in Iran were made before April 12, 2012, the investment activities in Iran
have not been expanded or renewed after April 12, 2012, and the Bidder/Proposer has adopted,
publicized and is implementing a formal plan to cease the investment activities in Iran and to refrain
from engaging in any new investments in Iran; or
2 The County has made a determination that the goods or services are necessary for the County to
perform its functions and that, absent such an exemption, the County would be unable to obtain the
goods or services for which the Bid/Proposal is offered. Such determination shall be made by the
County in writing and shall be a public document.

CONFLICT OF INTEREST DISCLOSURE
Conflict of Interest Disclosure Form
Note: A potential or actual conflict of interest exists when commitments and obligations are likely to be
compromised by the nominator(s)'other material interests, or relationships (especially economic),
particularly if those interests or commitments are not disclosed.
This Conflict of Interest Form should indicate whether the nominator(s) has an economic interest in, or
acts as an officer or a director of, any outside entity whose financial interests would reasonably appear to
be affected by the contract. The nominator(s) should also disclose any personal, business, or volunteer
affiliations that may give rise to a real or apparent conflict of interest. Relevant Federally and
organizationally established regulations and guidelines in financial conflicts must be abided by.
Individuals with a conflict of interest should refrain from bidding and/or contracting.
Date:
Name:
Position:
Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or
circumstances that you believe could contribute to a conflict of interest:
___ I have no conflict of interest to report.
___ I have the following conflict of interest to report (please specify other nonprofit and for-profit
boards you (and your spouse) sit on, any for-profit businesses for which you or an immediate family
member are an officer or director, or a majority shareholder, and the name of your employer and any
businesses you or a family member own):
1. -----------------------------
2. ------------------------------
3. ------------------------------
I hereby certify that the information set forth above is true and complete to the best of my knowledge.
Signature: _____________________
Company: _____________________
Date: ______________________
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