Form 22 - Suffolk County Contractor'S/vendor'S Public Disclosure Statement 2013
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2Suffolk County Form 22
Contractor’s/Vendor’s Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement must be
completed by all Contractors/vendors that have a Contract with Suffolk County, with the exception of hospitals;
educational or governmental entities; not-for-profit corporations; and Contracts providing foster care, family
day care providers, or child protective consulting services, who do not have to fill out this form at all.
1.
Contractor’s/Vendor’s Name_____________________________________________________________
Address_____________________________________________________________________________
City and State________________________________________________Zip Code__________________
2.
Contracting Department’s Name___________________________________________________________
Address______________________________________________________________________________
3.
Payee Identification or Social Security No.___________________________________________________
4.
Type of Business:
_____Corporation
_____Partnership
_____Sole Proprietorship
_____Other
5.a
Is Contractor/vendor entering into or has Contractor/vendor entered into a Contract with Suffolk County in
excess of $1,000? _____Yes _____No.
5.b
Has Contractor/vendor entered into three or more Contracts, including the one for which you are now
completing this form, with Suffolk County, any three of which, when combined, exceed $1,000?
____Yes ____No.
6.
Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Board
of Directors or comparable body, names and addresses of all partners, and names and addresses of all
corporate officers. Conspicuously identify any person in this table of organization who is also an officer or an
employee of Suffolk County. (Attach additional sheet if necessary.)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
7.
List all names and addresses of those individual shareholders holding more than five percent (5%) interest in
the Contractor/vendor. Conspicuously identify any shareholder who is also an officer or an employee of
Suffolk County. (Attach additional sheet if necessary).
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
8.
Does Contractor/vendor derive 50% or more of its total revenues from its contractual or vendor relationship
with Suffolk County? ____Yes ____No.
9.
If you answered yes to 8 above, you must submit with this disclosure statement, a complete financial
statement listing all assets and liabilities as well as a profit and loss statement. These statements must be
certified by a Certified Public Accountant. (Strike this out if not applicable.)
10.
The undersigned shall include this Contractor’s/Vendor’s Public Disclosure Statement with the Contract. (Describe
general nature of the Contract
____
___________________________________________________________________________________________
11.
Remedies. The failure to file a verified public disclosure statement as required under local law shall constitute
a material breach of Contract. Suffolk County may resort, use or employ any remedies contained in Article II
of the Uniform Commercial Code of the State of New York. In addition to all legal remedies, Suffolk County
Page 1 of 2
Rev. 5/2013
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