2011 Request For Proposal Cover Sheet Template Page 10
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11STATE OF CONNECTICUT, Department of Public Health RFP # 2011-0917; Tobacco Use Cessation Services
APPLICATION FORMS
OPM ETHICS FORM 5
STATE OF CONNECTICUT
CONSULTING AGREEMENT AFFIDAVIT
Affidavit to accompany a State contract for the purchase of goods and services with a
value of $50,000 or more in a calendar or fiscal year, pursuant to Connecticut General
Statutes §§ 4a-81(a) and 4a-81(b)
INSTRUCTIONS:
If the bidder or vendor has entered into a consulting agreement, as defined by
Connecticut General Statutes § 4a-81(b)(1):
Complete all sections of the form.
If the
bidder or vendor has entered into more than one such consulting agreement, use a separate form
for each agreement. Sign and date the form in the presence of a Commissioner of the Superior
Court or Notary Public.
If the bidder or vendor has not entered into a consulting
agreement, as defined by Connecticut General Statutes § 4a-81(b)(1): Complete only the
shaded section of the form. Sign and date the form in the presence of a Commissioner of the
Superior Court or Notary Public.
Submit completed form to the awarding State agency with bid or proposal. For a sole source
award, submit completed form to the awarding State agency at the time of contract execution.
This affidavit must be amended if the contractor enters into any new consulting agreement(s)
during the term of the State contract.
AFFIDAVIT: [ Number of Affidavits Sworn and Subscribed On This Day: _____ ]
I, the undersigned, hereby swear that I am the chief official of the bidder or vendor awarded a
contract, as described in Connecticut General Statutes § 4a-81(a), or that I am the individual
awarded such a contract who is authorized to execute such contract. I further swear that I have
not entered into any consulting agreement in connection with such contract, except for the
agreement listed below:
______________________________________________________________________________
Consultant’s Name and Title
Name of Firm (if applicable)
__________________
___________________
___________________
Start Date
End Date
Cost
Description of Services Provided:
______________________________________________________________________________
______________________________________________________________________________
Is the consultant a former State employee or former public official?
YES
NO
If YES: ___________________________________
__________________________
Name of Former State Agency
Termination Date of Employment
Sworn as true to the best of my knowledge and belief, subject to the penalties of false statement.
___________________________ ____________________________ __________________
Printed Name of Bidder or Vendor Signature of Chief Official or Individual
Date
___________________________________
___________________
Printed Name (of above)
Awarding State Agency
Sworn and subscribed before me on this _______ day of ____________, 20___.
___________________________________
Commissioner of the Superior Court
or Notary Public
RFP # 2011-0917 APPLICATION FORMS
Page 10 of 11
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