HomeMy WebLinkAboutOffice for the Aging-Bus LeaseHon~ I~live~at M~is
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RECEIVED
To: Elizabeth E. Neville, Town Clerk
OCT - 5 2005
From: Jane Edstrom, HRC
Soul'hold Town Clerk
Re: New Vehicle fxom Suffolk County
Date: 10/4/05
Karen asked that I forward these papers to you to keep on file. We will also re~'m a copy
in our files at the Human Resource Center.
The original registration was sent to Lynda Bohn to add to her "collection."
We are calling this 14 passenger bus "NI0' (which replaces a former NI0 van that was
declared as surplus and is now gone)
County of Suffolk
Steve Levy
Suffolk County Executive
Office for the Aging
Holly S, Rhodes-Teague
Director
RECEIVED
OCT - 5 2005
September 30, 2005
Southold Town Clerk
The Honorable Joshua Y. Horton
Supervisor
Town of Southold
53095 Main Road, P.O. Box 1179
Southold, New York 11971-0959
Vehicle Lease Agreement
Agreement No. 525-CAP-CAP-1749.516-009
Vin # 1FDXE45S35HA76740
Dear Supervisor Horton:
The fully executed agreement referenced above is enclosed for your files.
Sincerely,
Leonor Hunter
Fiscal Administrator
LH:TMB:lw
Enclosure
cc: Karen McLaughlin
(631) 8534200
H Lee Dennison Building · 100 Veterans Memorial Highway · P O Box 6100 · Hauppauge, New York 11788~)099 · FAX 853-8225
Over 30 years as the designated Area Agency on Aging Providing Services for Older Citizens
County of Suffolk
Steve Levy
Suffolk County Executive
Office for the Aging
Holly S. Rhodee-Teague
Director
July 14, 2005
The Honorable Joshua Y. Horton
Supervisor
Town of Southold
53095 Main Road, P.O. Box 1179
Southold, New York 11971-0959
Re:
Lease Agreement for 2005 Ford Phoenix 14 Passenger Bus
Vehicle Identification No. 1FDXE45S35HA76740
Dear Supervisor Horton:
In accordance with paragraph 2 of Exhibit A of the Lease Agreement for the vehicle(s) referenced above,
please sign both copies of this memorandum in the space provided below to acknowledge that the delivery
date of said vehicle was 10 - q -0 ~ , which is to be considered the Commencement Date of said
Lease.
Signed: Name ~ Date
/o s-HU~ Y .-- Hor to-~
(Type name under signature)
Title: supervisor
Signed: NameC-~I 0~ ,g~. ~%:~.~'~.. ~,4E4;~;~ Date
Title: Directon(QJ'fice for the Aging
Please keep one signed original of this memorandum with the executed lease Agreement which was sent to
you previously, and return one signed original of this memorandum to this office for our files.
Very truly yours,
Leonor Hunter
Fiscal Administrator II
LH:MVK:Iw
(631) 6534200
H. Lee Dennison Building · 100 Velerans Memorial Highway · P.O. Box 6100 · Hauppauge, New Yor~ 11788-009g · FAX 853-8225
Over 30 years as the designated Ar~a Agency on Aging Providing Services for Older Citizens
· ~ Agreement No. 525-CAP-CAP-1749.516-009
· Law No. AG023M/00 ~-15 N
~/ehicle Lease
Lease Agreement
This Agreement of Lease is between the County of Suffolk (Lessor), a municipal
corporation of the State of New York, having its principal office at the County Center, Riverhead,
New York 11901, acting through its duly constituted Office for the Aging (Aging), located at H.
Lee Dennison Building, 100 Veterans Memorial Highway, P. O. Box 6100, Hauppauge, New York
11788-0099; and the Town of Southold (Lessee), a New York municipal corporation, having its
principal place of business at 53095 Main Road, P.O. Box 1179, Southold, NY 11971-0959.
The parties hereto desire to provide transportation for elderly residents of Suffolk County to
enable them to participate in County, State and/or Federal programs for the elderly.
Term of Agreement: Shall be from the Commencement Date (as defined in Exhibit
A) in 2005 through December 31,2015, unless terminated or
extended as provided in Exhibit A.
Total Cost of Agreement: No Cost to County
Terms and Conditions: Shall be as set forth in Exhibit A attached.
In Witness Whereof, the parties hereto have executed this Agreement as of the latest date
written below.
Town of Southold
F/'~d. T aS;pPae;i;;l~# 11-6001939
County of Suffolk
Paul Sabatino II
Chief Deputy County Executive
Date: C~/~f, / ~0.(
Approved:
Approved as to Legality: __
Christine Mala~ / ~ By ~ ,~ ~--~i2:Z~ ~/7~
Suffolk Co;-n'~"A'~torn~ / /~ )- Holly Smhod~s-Teague ~ Dat~
~z,~r~){ ,~k~/,~/. ,Director, Office for the Aging
JSam~ntha-147rv~'dCachin Date / / /,/ . / /
Assistant County Attorney B · / E)
./ y. ( ,/,-...-.--
"~na Prencipe ~' Dat~
/Food Service Supervisor
AG23 (02~00)
Law No. AG023M/00 -15 N Agreement No. 525-CAP-CAP-1749.516-009
~/ehicle Lease
TABLE OF CONTENTS
EXHIBIT A
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
PURPOSE OF LEASE; USE OF VEHICLE ................................................................ 1
TERM ......................................................................................................................... 1
RENT .......................................................................................................................... 1
TITLE AND REGISTRATION ..................................................................................... 1
CONDITION AND MAINTENANCE ............................................................................ 1
ALTERATIONS AND ADDITIONS ............................................................................. 1
SOLE RESPONSIBILITY OF LESSEE ...................................................................... 2
OPERATIONAL INFORMATION AND INSPECTIONS .............................................. 2
COMPLIANCE WITH REQUIREMENTS .................................................................... 2
CONTACT PERSONS ................................................................................................ 2
RISK OF LOSS; INSURANCE AND INDEMNIFICATION .......................................... 2
ACCIDENT NOTIFICATION ....................................................................................... 4
DAMAGE TO OR DESTRUCTION OF VEHICLE ...................................................... 4
APPLICATION OF INSURANCE PROCEEDS ........................................................... 4
NONDISCRIMINATION AND AFFIRMATIVE ACTION IN EMPLOYMENT ............... 4
ASSURANCE OF COMPLIANCE WITH CIVIL RIGHTS LAWS ................................ 5
OFFSET OF ARREARS OR DEFAULT ..................................................................... 5
NO GRATUITIES ....................................................................................................... 5
TERMINATION OF LEASE ........................................................................................ 5
EXTENSION OF LEASE ............................................................................................ 5
END OF TERM; RENTAL CHARGES ........................................................................ 6
INDEPENDENT CONTRACTOR ............................................................................... 6
ASSIGNABILITY ........................................................................................................ 6
PUBLICATIONS ........................................................................................................ 6
SEVERABILITY; NO IMPLIED WAIVER .................................................................... 6
ENTIRE AGREEMENT .................................................................................. 6
NO ORAL CHANGES ................................................................................................. 6
EXHIBIT B
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Law No. AG023M/00 -15 N Agreement No. 525-CAP-CAP-1749.516-009
Vehicle Lease
Exhibit A
1. Purpose of Lease; Use of Vehicle
The purpose of this Lease is to assist the Lessee in providing services to elderly residents
of Suffolk County under contract(s) between the Lessor and the Lessee by the leasing to the
Lessee of a Lessor-owned vehicle more particularly described in Exhibit B to this Agreement (the
"Vehicle"), and Lessee hereby leases the Vehicle from Lessor solely for the purpose of
furnishing transportation or other services (such as meals to the homebound) for elderly residents
of Suffolk County under such separate contract or contracts as may be in effect from time to time
during the term of this Agreement between the Lessor, acting through Aging (or such other
Lessor office, department or instrumentality as may succeed to the functions of Aging), and the
Lessee; provided however, that Lessee shall not use the Vehicle for any other purpose
whatsoever without the prior written consent of the Director of the Suffolk County Office for the
Aging (or other Lessor official designated to succeed to such Director's functions). Under no
circumstances shall the Lessee use the Vehicle in any way contrary to applicable laws,
regulations or insurance requirements.
2. Term
'This Lease shall cover the period provided on the first page thereof, unless sooner
terminated as provided in paragraph 19 or extended as provided in paragraph 20 below.
"Commencement Date" shall mean the date of delivery of the Vehicle to the Lessee, and "Lease
Year" shall mean the 12-month period commencing on the Commencement Date or any
anniversary thereof and ending on the day before the next ensuing anniversary thereof, both
inclusive. Promptly after delivery, Aging and the Lessee shall sign a memorandum confirming the
Commencement Date.
3, Rent
The Lessee shall pay the Lessor one dollar ($1.00) per Lease Year, receipt waived, so
long as the Lessee shall use the Vehicle for the purposes specified in paragraph 1 of this Lease,
and thereafter rental charges as provided in paragraph 21 below until return of the Vehicle to the
Lessor.
4. Title and Registration
Title to the Vehicle and to all replacements, alterations and additions thereto shall be and
remain in the name of the Lessor, but the Lessee shall register the Vehicle in its name as
lessee, and the Lessor shall cooperate with the Lessee by temporarily entrusting the certificate
of title to the Lessee and otherwise as may be appropriate to procure and maintain such
registration.
5. Condition and Maintenance
Since the Vehicle is a new vehicle, all manufacturers' warranties are hereby assigned by
the Lessor to the Lessee, and the Lessor shall cooperate with Lessee in obtaining warranty
period labor and parts. Lessee has reviewed the purchase specifications for the Vehicle and
represents that it is familiar therewith and with the owner's and service manuals. Lessee, at
AG23 (02/00)
Page 1 of 7 of Exhibit A
Law No. AG023M/00
Vehicle Lease
-15N
Agreement No. 525-CAP-CAP-1749.516-009
Lessee's sole cost and expense, shall perform or cause to be performed all work, ordinary and
necessary, foreseen and unforeseen, to maintain the Vehicle in good working order and
appearance and in accordance with the manufacturer's manuals and recommended practices.
6, Alterations and Additions
If Lessee is not in default under this Lease, Lessee, at its sole expense, may make
reasonable alterations of and additions to the Vehicle with the written approval of Aging;
provided that any such alterations or additions
(a) Shall not change the general character of the Vehicle, reduce its fair market value
below such value immediately before such alterations or additions or impair its usefulness
for the purpose provided in paragraph 1 of this Lease;
(b) Are effected with due diligence, in a good and workmanlike manner and in
compliance with applicable laws, regulations and insurance requirements; and
(c) Are promptly and fully paid for by Lessee.
1. Sole Responsibility of Lessee
Nothing in this Lease or in any approval under the foregoing paragraph 6 shall constitute
any consent or request by the Lessor, express or implied, for the performance of any labor or
services or the furnishing of any materials or other property in connection with the Vehicle or any
part or equipment thereof, and nothing in this Lease shall give Lessee any right or authority to
contract for or permit the performance of any labor or services or the furnishing of any materials
or other property for the account of or as a liability or obligation of the Lessor.
8. Operational Information and Inspections
Lessee shall provide such information relating to the use and operation of the Vehicle as
may be requested from time to time by the Lessor.
Upon written notification from Aging, Lessee shall make the Vehicle available for
inspection at reasonable times and locations. The Lessor shall not have any duty to make any
such inspection and shall not incur any liability or obligation for not making such inspection.
9. Compliance With Requirements
Lessee, at its sole expense, shall promptly
(a) Comply with all legal requirements, whether or not such compliance shall require
structural changes in the Vehicle or interfere with its use, and
(b) Procure, maintain and comply with all permits, licenses or other authorizations and
comply with all applicable Federal, State, County and local laws, regulations or rulings, applicable
to the Vehicle or to Lessee's use thereof.
10. Contact Persons
The contact persons for the parties to this Lease shall be: for the Lessor, the Director of
the Office for the Aging; for the Lessee, the signer of this Agreement on behalf of its behalf; or
such other person of whose name and title either party shall give prompt written notice to the
other party.
AG23 (O2~OO)
Page 2 of 7 of Exhibit A
· .Law No. AG023M/00 -15 N Agreement No. 525-CAP-CAP-1749.516-009
Vehicle Lease
11. Risk Of Loss; Insurance and Indemnification
(a) The Lessee assumes responsibility for all risks of loss through physical damage,
including without limitation collision and comprehensive losses, to the Vehicle and to any part or
equipment thereof.
(b) The Lessee agrees to procure, pay the entire premium for and maintain throughout
the term of this Agreement insurance in amounts and types specified by the Lessor. Unless
otherwise specified by the Lessor and agreed to by the Lessee, in writing, such insurance will be
as follows:
(i) COMMERCIAL GENERAL LIABILITY INSURANCE, insurance,
including contractual liability coverage, in an amount not less than Two
Million Dollars ($2,000,000.00) per occurrence for bodily injury and Two
Million Dollars ($2,000,000.00) per occurrence for property damage.
(ii) AUTOMOBILE LIABILITY INSURANCE in an amount not less than
Five Hundred Thousand Dollars ($500,000) per person, per accident, for
bodily injury and not less than One Hundred Thousand ($100,000.00) for
property damage per occurrence and PHYSICAL DAMAGE COVERAGE in
an amount equal to the value of the vehicle as described in the paragraph
below headed, "Damage to or Destruction of Vehicle".
(iii) WORKERS' COMPENSATION and EMPLOYER'S LIABILITY
INSURANCE in compliance with all applicable New York State laws
and regulations and DISABILITY BENEFITS INSURANCE if required
by law and shall have furnished to the Lessor prior to its execution of
this Agreement the documentation required by the State of New York
Workers' Compensation Board of coverage or exemption from
coverage pursuant to §§ 57 and 220 of the Workers' Compensation
Law. In accordance with General Municipal Law § 108, this Agreement
shall be void and of no effect unless the Lessee shall provide and
maintain coverage during the term of this Agreement for the benefit of
such employees as are required to be covered by the provisions of the
Workers' Compensation Law.
(c) All policies providing such coverage shall be issued by insurance companies
with an A.M. Best rating of A- or better.
(d) The Contractor shall furnish to the County Declaration Pages for each such
policy of insurance, and, upon request, a true and certified original copy of each such
policy, evidencing compliance with the aforesaid insurance requirements. In the case of
commercial general liability insurance, the County of Suffolk shall be named as an
additional insured and Contractor shall furnish a Declaration Page and endorsement page
evidencing the County's status as an additional insured on said policy·
(e) Furthermore, to the extent permitted by law, the Lessee shall indemnify and
hold harmless the Lessor, its consultant (if any), employees, agents and other persons
from and against all losses, claims, costs, judgments, liens, encumbrances and expenses,
including attorney's fees, by reason of liability imposed by law for damage because of
AG23 (02/00)
Page 3 of 7 of Exhibit A
· Law No. AG023M/00
~/ehicle Lease
-15 N
Agreement No. 525-CAP-CAP-1749.516-009
bodily injury, including death at any time resulting therefrom, sustained by any person or
persons, or on account of damage to property, arising out of the acts or omissions or
negligence of the Lessee, its agents, employees or subcontractors or of other persons, in
connection with the use of the vehicle described or referred to in this Agreement, even if
such injuries to persons or damage to property are due, or are claimed to be due, to
passive negligence of the Lessor, its employees, agents or subcontractors or other
persons, except only in cases of the Lessor's sole active negligence.
(f) It is further agreed that the Lessee will expend whatever funds are necessary
to insure that the Vehicle is properly maintained in operable condition.
(g) It is also agreed that the Lessee will return the Vehicle to the Lessor in the
same condition as when received except for normal wear and tear and mileage.
(h) Furthermore, in lieu of making necessary repairs to the Vehicle and returning
it upon the expiration or termination of this Lease as provided in paragraph 21 below, the
Lessee may at its option elect to pay the Lessor the fair market value of the Vehicle.
12, Accident Notification
(a) The Lessee shall notify the County in writing within twenty-four (24) hours after any
accident involving the vehicle. All such notifications, copies of claims and other communications
with regard to possible claims of liability shall be addressed to:
County of Suffolk
Division of Risk Management and Benefit
H. Lee Dennison Building, 100 Veterans Memorial Highway,
P.O. Box 6100, Hauppauge, New York 11788-0099
with a copy to Aging. Without limitation, such communications shall include a copy of any
accident report and the names and addresses of any persons alleging personal injury or property
damage in connection with such accident.
(b) Any communication or notice regarding termination or litigation shall also be sent to
the following addresses or at such other addresses that may be specified in writing by the Lessor
or the County Attorney:
Suffolk County Department of Law
H. Lee Dennison Building - 6th Floor
100 Veterans Memorial Highway
P.O. Box 6100
Hauppauge, New York 11788
Attn: Christine Malafi, County Attorney
13. Damage To Or Destruction Of Vehicle
In case of any material damage to or loss or destruction of the vehicle or of its equipment,
the Lessee shall give notice as provided in the foregoing paragraph headed, "Accident
Notification", generally describing the nature and extent of such damage, loss or destruction, and
the time, place and circumstances thereof, and shall promptly replace or repair the vehicle and/or
AG23 (02/00)
Page 4 of 7 of Exhibit A
" . Law No. AG023M/00 -15 N Agreement No. 525-CAP-CAP-1749.516-009
Vehicle Lease
its equipment at least to the condition that it was in immediately prior to the damage, loss or
destruction.
14. Application of Insurance Proceeds
In the event of damage to or loss or destruction of the Vehicle or any part or equipment
thereof, Lessee shall use any proceeds of insurance solely to repair or replace the Vehicle or its
equipment and for no other purpose, and, if not so used, such proceeds and the Vehicle shall be
forthwith turned over to the Lessor.
15. Nondiscrimination and Affirmative Action in Employment
The Lessee agrees in connection with the performance of this Agreement as follows:
(a) The Lessee shall not discriminate against employees or applicants for employment
because of race, creed, color, national origin, sex, age, disability, Vietnam Era Veteran status or
marital status, and will undertake or continue existing programs of affirmative action to ensure that
women and minority group members are afforded equal employment opportunities without
discrimination. Affirmative action shall mean recruitment, employment, job assignment, promotion,
upgradings, demotion, transfer, layoff, or termination and rates of pay or other forms of
compensation.
(b) The Lessee shall state, in all solicitations or advertisements for employees, that, in
the performance of this Agreement, all qualified applicants will be afforded equal employment
opportunities without discrimination because of race, creed, color, national origin, sex, age,
disability, Vietnam Era Veteran status or marital status.
16. Assurance of Compliance With Civil Rights Laws
The Lessee hereby assures that it will comply with Subchapter VI of the Civil Rights Act of
1964, 42 USC Sections 2000e through 2000e(17), to the end that no person shall, on the grounds
of race, creed, color, sex, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under this Lease or under any project,
program, or activity supported by this Lease.
17. Offset of Arrears or Default
The Lessee warrants that it is not, and shall not be during the term of this Agreement, in
arrears to the COUNTY for taxes or upon debt or contract and is not, and shall not be during the
term of this Agreement, in default as surety, contractor or otherwise on any obligation to the
COUNTY.
18. No Gratuities
The Lessee represents and warrants that it has not offered or given any gratuity to any
official, employee or agent of Suffolk County or New York State or of any political party, with the
purpose or intent of securing an agreement or securing favorable treatment with respect to the
awarding or amending of an agreement or the making of any determinations with respect to the
performance of an agreement, and that the signer of this Lease has read and is familiar with the
provisions of Local Law No. 32-1980 of Suffolk County (Chapter 386 of the Suffolk County Code).
AG23 (02/00)
Page 5 of 7 of Exhibit A
Law No. AG023M/00 -15 N Agreement No. 525-CAP-CAP-1749.516-009
'Vehicle Lease
19. Termination of Lease
(a) This Lease may be terminated by the Lessor in the event of failure by the Lessee
to fulfill its obligations under this Lease or in the event of the termination or expiration without
renewal of one or more of the contracts between the Lessor and the Lessee for services to the
elderly referred in paragraph 1 of this Agreement; provided that no such termination shall be
effective unless the Lessee is given three (3) calendar days' written notice of intent to terminate,
delivered personally or by certified mail, return receipt requested, and an opportunity for
consultation with the Lessor prior to termination.
(b) If either party shall deem it in its best interest to terminate this Lease, it shall have
the right to do so by giving not less than thirty (30) days prior written notice by registered or
certified mail, return receipt requested, specifying the date of termination.
20. Extension of Lease
Upon written notification by Aging to the Lessee, the term of this Lease may be extended
for one er more successive periods not in excess of five years per extension on the same terms
and conditions; provided, however, that the Lessee does not notify Aging within 30 days after the
receipt of such notification of its desire to terminate this Lease at an earlier date, in which event it
shall terminate at such earlier date.
21. End Of Term; Rental Charges
Upon the expiration of this Lease, or within 24 hours after other termination of this Lease,
Lessee shall surrender the Vehicle to Lessor at a facility of Lessor as designated by Aging. If
the Lessee fails to surrender the Vehicle, or for any period of use not authorized by this Lease,
the Lessee shall pay to the Lessor as rental for the use of the Vehicle $150 per day until the
Vehicle is surrendered to Lessor.
22. Independent Contractor
It is expressly agreed that the Lessee's status hereunder is that of an independent
contractor. Neither the Lessee nor any person hired by the Lessee shall be considered
employees of the Lessor for any purpose whatsoever.
23. Assignability
The Lessee shall not assign, transfer, convey, sublet or otherwise dispose of this Lease, or
any of its right, title or interest therein, or its power to execute this Lease, or assign all or any
portion of the monies that may be due or become due to the Lessee under the terms of this
Lease, to any other person or corporation, without the prior consent in writing of the Lessor, and
any attempt to do any of the foregoing without such consent shall be of no effect.
24. Publications
(a) The Lessee shall not issue or publish any book, article, announcement, report,
radio, television, data communication or other publication or publicity relating to the use of the
vehicle without prior written permission from the Lessor. Any such publication shall bear a
statement acknowledging the cooperation and/or funding by the County of Suffolk- Steve Levy,
County Executive.
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Page 6 of 7 of Exhibit A
Law No. AG023M/00 -15 N Agreement No. 525-CAP-CAP-1749.516-009
~/ehicle Lease
(b)
vehicle:
The Lessee shall maintain the following identifying text conspicuously on the
Funding Provided by Suffolk County
through the
Suffolk County Office for the Aging
25 Severability; No Implied Waiver
(a) It is expressly agreed that if any term or provision of this Agreement, or the
application thereof to any person or circumstance, shall, to any extent, be held invalid or
unenforceable, the remainder of this Agreement, or the application of such term or provision to
persons or circumstances other than those as to which it is held invalid or unenforceable, shall not
be affected thereby; and every other term and provision of this Agreement shall be valid and shall
be enforced to the fullest extent permitted by law.
(b) No waiver shall be inferred from any failure or forbearance of the Lessor to enforce
any provision of this Agreement in any particular instance or instances, but the same shall
otherwise remain in full force and effect notwithstanding any such failure or forbearance.
26, Entire Agreement
It is expressly agreed that this instrument represents the entire agreement of the parties
and that all previous understandings are merged in this Lease.
27. No Oral Changes
No modification of this Lease shall be valid unless written in the form of an Addendum or
Amendment signed by both parties.
-- End of Text --
AG23 (02/00)
Page 7 of 7 of Exhibit A
Manufacturer:
Type of Vehicle:
Year and Make:
Model No.:
Exhibit B
Vehicle Specifications for Lease Between
The County Of Suffolk and
Town of Southold
Ford Motor Company
14 Passenger Bus
2005 Ford Phoenix
E450
Vehicle Identification Number: 1FDXE45S35HA76740
Color: White
Other Identifyin,q Features and Special Equipment:
accommodates 2 wheelchairs/10 ambulatory;
2 forward facing flip seats
AG23 (02/00)
Southold vehicle agree 2005
Suffolk 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. In the event
contractor/vendor is exempt from completing paragraphs numbered 1 through 11 below, so indicate at
paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt
status, you must execute this form below before a notary public.
Contractor,s/Vendor's Name
Address ~/. t~. /~ ~
City ~d State 5 o ~x~ ~.
Contracting De~a~ment's Na~
Address
Zip Code
5.b
Payee Identification or Social Security No.
Type of Business__Corporation._Partnership__Sole Proprietorship~Other
Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk
County in excess of $1,0007 Yes No.
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
$1,0007 Yes No.
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.)
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).
10.
Does contractor/vendor derive 50% or more of its total revenues fi.om its contractual or vendor
relationship with Suffolk County?.__Yes__ No.
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.)
The undersigned shall include this Contractor's/vendor's Public Disclosure Statement with the
contract. (Describe general nature of the contract.).
Page 1 of 3 Public Disclosure Form
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 shall be entitled, upon a determination that a
breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract.
12. If you are one of the entities listed below at a) through c) or you qualify under d) below, you are
exempt from completing paragraphs numbered 1 through I 1 herein:
a) Hospital
x,,/' b) Educational or governmental entities
c) Not-for-profit corporations
d) Contracts providing for foster care, family day-care providers or child protective
services
Please check to the left side of the appropriate exemption.
13.
Dated:
Printed Name of Signer:
Title of Signer:
Name of Contractor/Vendor:
Verification. This section must be signed by an officer or principal of the contractor/vendor
authorized to sign for the company for the purpose of executing contracts. The undersigned
being sworn, affirms under the penalties of perjury, that he/she has read and understood the
foregoing statements and that they are, to his0aer own knowledge, true.
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(~Vithin New York State)
STATE OF NEW YORK)
COUNTY OF ) ss.:
On the ~ day of .~(e~.~/~P_.4 in the year 200~efore me, the undersigned, personally appeared
._~o~]t.,~. f, _.~. ~-o,~ //personally known to me or proved to me on the basis of satisfactory evidence
to be the individual(s) whose name(s) is (are) subscribed to the within instrument and ackno~vledged to
me that he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s)
the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed
ment. ~ A
office of individual taking acknowledgement)
KIERAN M. CORCORAN
~lotary Public, State of New
No. 02C06119838
Qualified in SuffoJk County
,~,*.,~io, Expires Decembe~ 6, 20~_.~
Page 2 of 3 Public Disclosure Form
UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT
(Without New York State)
STATE OF )
)SS.:
COUNTY OF )
On the day of in the year 2004 before me, the undersigned, personally
appeared personally known to me or proved to me on the basis of
satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument
and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies) and that by
his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the
individual(s) acted, executed the instrument, and that such individual(s) made such appearance before
the undersigned in
(Insert the city or other political subdivision and the state or country or other place the acknowledgement
was taken)
(signature and office of individual taking acknowledgement)
Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04)
Page 3 of 3 Public Disclosure Form
H:\TBlumenauer~member items 2005\master forms\pub disc form22.doc