Certification Form Of No Change
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1DIRECTIONS: Please execute two originals (both with original signature).
Please forward directly to the agency (not M.O.C.S.).
CERTIFICATION OF NO CHANGE
A MATERIALLY FALSE STATEMENT WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION
WITH THIS CERTIFICATION, AND/OR THE FAILURE TO CONDUCT APPROPRIATE DUE
DILIGENCE IN VERIFYING THE INFORMATION THAT IS THE SUBJECT MATTER OF THIS
CERTIFICATION, MAY RESULT IN RENDERING THE SUBMITTING ENTITY NON-RESPONSIBLE
FOR THE PURPOSE OF CONTRACT AWARD, AND A MATERIALLY FALSE STATEMENT
WILLFULLY OR FRAUDULENTLY MADE IN CONNECTION WITH THIS CERTIFICATION MAY
SUBJECT THE PERSON MAKING THE FALSE STATEMENT TO CRIMINAL CHARGES.
Submitting entity___________________________________________________________
Are you submitting this Certification as a parent?
Yes
/
No
EIN/TIN______________________
Address_____________________________________________
Agency ____________________________________________
I, _________________________, being duly sworn, state that I have read and understand all the
items contained in the _______ questionnaire, dated __________ [if applicable: and the
submission(s) dated ________, updating the information in that questionnaire]; and that, to the best
of my knowledge, information and belief, the answers contained in the _____ questionnaire
[if applicable: as modified by the submission(s) dated _________,] are full, complete, and accurate;
and that, to the best of my knowledge, information, and belief, those answers continue to be full,
complete, and accurate. I further certify on behalf of the submitting vendor that the information
contained in the principal questionnaires for _____________________, dated ___________,
___________________, dated _________, _____________________, dated ___________,
[if applicable: and the submission(s) dated ________, updating the information in those
questionnaires] has been verified and continues to the best of my knowledge to be full, complete and
accurate. I understand that the City of New York will rely on the information supplied in this
certification as additional inducement to enter into a contract with the submitting entity.
Sworn to before me this
day of
20
___________________________________
___________________
_______________
Notary Public
County License Issued
License Number
BY ______________________________________________
Print name
____________________________________________
Title
__________________________________________
____________________
Signature
Date
ON BEHALF OF ____________________________________
Name of submitting entity
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