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CONTRACT FACE PAGE
STATE AGENCY
New York State Department of State
41 State Street
Albany, New York 12231
BOX 1 - CONTRACTOR (Name and Business Address)
Town of Soutllliold
53095 Main Road
P.O. Box 1179
Southo1d, NY 11971-0959
BOX 2 - FEDERAL TAX In NUMBER
-1 ...l.. 6 0 0 1 9 3 9
BOX 3 - STATUS
Sectarian entity?
Not-for-profit organization?
Yes _ No x:.
Yes No-x
lititBi'~i?UNDs CFDA #: NIA
(;QNTRACTPERIOD:
04/1)1/2005 TO: 07/31/2007
11\\tulm:,;YEAR TERM: NIA
"~PM: ,',' TO:
I
I
FV~D,N9FOR INITIAL PERIOD:
\::',C,~:<i':,':v,:<:;~r,,',:;_,:i'>",,' :,-' ,;,,'i~: -,' ':: -. ; , '" ,':: :",' ' -,':
$10,000.0()
BOX4-CHARITIESREGISTRATIONNUMBER..liIh.... -_ _ -_ _/EXEMPTION(u)-__
EST A TES, POWERS AND TRUSTS LAWS REPORTING EXEMPTION (E-3) -
BOX 5 - If you did not claim ap. exemption to both of the items in Box 4, you must check the applicable
response in the following: AJ 0-
Contractor has _I has not _ timely filed with the Attorney General's Charities Bureau all required
periodic or annual written reports.
APPENDICES ATTACHED TO AND PART OF THIS AGREEMENT
APPENDIX A:
APPENDIX AI:
APPENDIX B:
APPENDIX C:
APPENDIX D:
APPENDIX E:
APPENDIX X:
Standard Clauses as Required by the Attorney General for all State Contracts
Agency-specific Clauses
Budget
Payment and Reporting Schedule
Program Workplan
Charities Bureau Registration and Reporting Exemptions
Modification Agreement Form (to accompany modified appendices for changes in term or
consideration on an existing period or for renewal periods)
2005,2006 LMI
SIGNATURE PAGE
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below
their signatures.
CONTRACT #TMSI097
CONTRACTOR
STATE AGENCY
By:
..G~n&/~F
New York State Department of State
By:
Town of Southold
(Print Name)
~,...t"l~t- no "Rl1c!c!Q1l
(Print Name)
Title:
Date:
State Agencv Certification
"In addition to the acceptance of this Contract, I also certify
that original copies of this signature page will be attached
to all other exact copies of this Contract."
Title:
Date:
Supervisor
~j,lc(.;
STATE OF NEW YORK)
COUNTY OF 5u.Ffut-jt..}ss.:
On this /7rL day of August , in the year 20~, before me personally
appeared ~ (" n +to. R 'I ~ ~ ..11 , to me known, who being by
me duly sworn, did depose and say that he~!!lOi:is the Supervisor of
the Town of Southold , the organization described
in and which executed the above instrument; and that he/she has the authority to sign on behalf of
said organization; and that he/she executed the foregoing agreement for and in behalf of said
organization.
14UY (/h -p to ;--~_hU
Notary ublic
LINDA J COOPER
NOTARY PUBLIC, State of New York
~~~O~~r8~~26;~;~~~f:~I~, ~~u2Jb
APPROVED:
ATTORNEY GENERAL'S SIGNATURE:
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
Title:
Date:
SIGNATURE PAGE
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below
their signatures.
CONTRACT #TM51097
CONTRACTOR
STATE AGENCY
By:
~~E~
New York State Department of State
By:
Town of Southold
Scott A. Russell
{Print Name)
Title:
Title:
Supervisor
(PrinIName)
clj,
'" //'7; c(
/
Date:
State Agencv Certification
"In addition to the acceptance of this Contra,ct, I also certify
that original copies of this signature page will be attached
to all other exact copies of this Contract."
Date:
STATE OF NEW YORK)
COUNTY OF SUFFOLK) ss.:
On this J 7 day of Augus t
appeared Scot t A. Rus sell
me duly sworn, did depose and say that he/llm is the
the Town of Southold
, in the year 20~, before me personally
, to me known, who being by
Supervisor of
, the organization described
in and which executed the above instrument; and that he/she has the authority to sign on behalf of
said organization; and that he/she executed the foregoing agreement for and in behalf of said
organization.
~d~ () (J ~V'.,.t~
'Notary Public
LINDA J COOPER
NOTARY PUBLIC. State of New York
NO, 01C04822563, Suffolk County,
Term Expires December31120~
APPROVED:
ATTORNEY GENERAL'S SIGNATURE:
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
Title:
Date:
SIGNA TURE PAGE
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below
their signatures.
CONTRACT #TM51097
CONTRACTOR
STATE AGENCY
Town of Southold
By:
J..4~
Scott A. Russell
New York State Department of State
By:
(PnntName)
Title:
Title:
Date:
. (Print Name)
SUperV1.S0r
8//~r:
I
Date:
State Agencv Certification
"In addition to the acceptance ofthis Contract, I also certify
that original copies of this signature page will be attached
to all other exact copies of this Contract."
STATE OF NEW YORK)
COUNTYOF-'~)ss.:
On this I") day of August ,in the year 20~, before me personally
appeared Scott A. Russell ,tomeknown,whobeingby
me duly sworn, did depose and say that he/~ is the Supervisor of
the Town of Southold , the organization described
in and which executed the above instrument; and that he/she has the authority to sign on behalf of
said organization; and that he/she executed the foregoing agreement for and in behalf of said
organization.
~ () 6~--o,uU
Notary Public
LINDA J COOPER
NOTARY PUBLIC. State of New York
NO. 01 C04822563, Suffolk County.
Term Expires December 31, 20..t2I!-
APPROVED:
ATTORNEY GENERAL'S SIGNATURE:
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
Title:
Date:
I
STATE OF NEW YORK
AGREEMENT
This AGREEMENT is hereby made by and between the State of New York
agency (STATE) and the public or private agency (CONTRACTOR) identified on the
face page hereof.
WITNESSETH:
WHEREAS, the STATE has the authority to regulate and provide funding forthe
establishment and operation of program services and desires to contract with skilled
parties possessing the necessary resources to provide such services; and
WHEREAS, the CONTRACTOR is ready, willing and able to provide such
program services and possesses or can make available all necessary qualified
personnel, licenses, facilities and expertise to perform or have performed the services
required pursuant to the terms of this AGREEMENT;
NOW, THEREFORE, in consideration of the promises, responsibilities and
covenants herein, the STATE and the CONTRACTOR agree as follows:
1. Conditions of Agreement
A. This AGREEMENT may consist of successive periods (PERIOD), as
specified within the AGREEMENT or within a subsequent Modification
Agreement(s) (Appendix X). Each additional or superseding PERIOD shall
be on the forms specified by the particular State agency, and shall be
incorporated into this AGREEMENT.
B. Funding for the first PERIOD shall not exceed the funding amount specified
on the face page hereof. Funding for each subsequent PERIOD, if any, shall
not exceed the amount specified in the appropriate appendix for that
PERIOD.
C. This AGREEMENT incorporates the face pages attached and all of the
marked appendices identified on the face page hereof.
2
D. For each succeeding PERIOD ofthis AGREEMENT, the parties shall prepare
new appendices, to the extent that any require modification, and a
Modification Agreement (the attached Appendix X is the blank form to be
used). Any terms of this AGREEMENT not modified shall remain in effect
for each PERIOD of the AGREEMENT.
To modify the AGREEMENT within an existing PERIOD, the parties shall
revise or complete the appropriate appendix formes). Any change in the
amount of consideration to be paid, or change in the term, is subject to the
approval of the Office of the State comptroller. Any other modifications
shall be processed in accordance with agency guidelines as stated in
Appendix AI.
E. The CONTRACTOR shall perform all services to the satisfaction of the
STATE. The CONTRACTOR shall provide services and meet the program
objectives summarized in the Program Workplan (Appendix D) in accordance
with: provisions of the AGREEMENT; relevant laws, rules and regulations,
administrative and fiscal guidelines; and where applicable, operating
certificates for facilities or licenses for an activity or program.
F. lfthe CONTRACTOR enters into subcontracts for the performance of work
pursuant to this AGREEMENT, the CONTRACTOR shall take full
responsibility for the acts and omissions of its subcontractors. Nothing in the
subcontract shall impair the rights of the STATE under this AGREEMENT.
No contractual relationship shall be deemed to exist between the
subcontractor and the STATE.
G. Appendix A (Standard Clauses as required by the Attorney General for all
State contracts) takes precedence over all other parts of the AGREEMENT.
II. Payment and Reporting
A. The CONTRACTOR, to be eligible for payment, shall submit to the STATE's
designated payment office (identified in Appendix C) any appropriate
documentation as required by the Payment and Reporting Schedule
(Appendix C) and by agency fiscal guidelines, in a manner acceptable to the
STATE.
3
B. The STATE shall make payments and any reconciliations in accordance with
the Payment and Reporting Schedule (Appendix C). The STATE shall pay
the CONTRACTOR, in consideration of contract services for a given
PERIOD, a sum not to exceed the amount noted on the face page hereof or
in the respective Appendix designating the payment amount for that given
PERIOD. This sum shall not duplicate reimbursement from other sources for
CONTRACTOR costs and services provided pursuant to this AGREEMENT.
C. The CONTRACTOR shall meet the audit requirements specified by the
STATE.
III. Terminations
A. This AGREEMENT may be terminated at any time upon mutual written
consent of the STATE and the CONTRACTOR.
B. The STATE may terminate the AGREEMENT immediately, upon written
notice oftermination to the CONTRACTOR, if the CONTRACTOR fails to
comply with the terms and conditions of this AGREEMENT and/or with any
laws, rules, regulations, policies or procedures affecting this AGREEMENT.
C. The STATE may also terminate this AGREEMENT for any reason III
accordance with provisions set forth in Appendix AI.
D. Written notice of termination, where required, shall be sent by personal
messenger service or by certified mail, return receipt requested. The
termination shall be effective in accordance with the terms of the notice.
E. Upon receipt of notice of termination, the CONTRACTOR agrees to cancel,
prior to the effective date of any prospective termination, as many
outstanding obligations as possible, and agrees not to incur any new
obligations after receipt of the notice without approval by the STATE.
F. The STATE shall be responsible for payment on claims pursuant to services
provided and costs incurred pursuant to terms of the AGREEMENT. In no
event shall the STATE be liable for expenses and obligations arising from the
program(s) in this AGREEMENT after the termination date.
4
IV. Indemnification
A. The CONTRACTOR shall be solely responsible and answerable in damages
for any and all accidents and/or injuries to persons (including death) or
property arising out of or related to the services to be rendered by the
CONTRACTOR or its subcontractors pursuant to this AGREEMENT. The
CONTRACTOR shall indemnify and hold harmless the STATE and its
officers and employees from claims, suits, actions, damages and costs of
every nature arising out of the provision of services pursuant to this
AGREEMENT.
B. The CONTRACTOR is an independent contractor and may neither hold itself
out nor claim to be an officer, employee or subdivision of the STATE nor
make any claim, demand or application to or for any right based upon any
different status.
V. Property
Any equipment, furniture, supplies or other property purchased pursuant to this
AGREEMENT is deemed to be the property of the STATE except as may
otherwise be governed by Federal or State laws, rules or regulations, or as stated
in Appendix AI.
VI. Safeguards for Services and Confidentiality
A. Services performed pursuant to this AGREEMENT are secular in nature and
shall be performed in a manner that does not discriminate on the basis of
religious belief, or promote or discourage adherence to religion in general or
particular religious beliefs.
B. Funds provided pursuant to this AGREEMENT shall not be used for any
partisan political activity, or for activities that may influence legislation or
the election or defeat of any candidate for public office.
C. Information relating to individuals who may receive services pursuant to this
AGREEMENT shall be maintained and used only for the purposes intended
under the Contract and in conformity with applicable provisions ofIaws and
regulations, or specified in Appendix AI.
A-I
APPENDIX A
Standard Clauses for All New York State Contracts
The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, "the contract" or "this contract") agree
to be bound by the following clauses which are hereby made a part of the
contract (the word "Contractor" herein refers to any party other than the
State, whether a contractor, licenser, licensee, lessor, lessee or any other
party):
I. EXECUTORY CLAUSE. In accordance with Section 41 of the State
Finance Law, the State shall have no liability under this contract to the
Contractor or to anyone else beyond funds appropriated and available for
this contract.
2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of
the State Finance Law, this contract may not be assigned by the Contractor
or its right, title or interest therein assigned, transferred conveyed, sublet or
otherwise disposed of without the previous consent, in writing, of the State
and any attempts to assign the contract without the State's written consent
are null and void The Contractor may, however, assign its right to receive
payment without the State's prior written consent unless this contract
concerns Certificates of Participation pursuant to Article 5-A of the State
Finance Law.
3. COMPTROLLER'S APPROVAL In accordance with Section 112 of
the State Finance Law (or, if this contract is with the State University or
City University of New York, Section 355 or Section 6218 of the Education
Law), if this contract exceeds $15,000 (or the minimum thresholds agreed
to by the Office of the State Comptroller for certain S.U.N.Y. and C.UN.Y.
contracts), or if this is an amendment for any amount to a contract which,
as so amended, exceeds said statutory amount, or if, by this contract, the
State agrees to give something other than money when the value or
reasonably estimated value of such consideration exceeds $1 0,000, it shall
not be valid, effective or binding upon the State until it has been approved
by the State Comptroller and filed in his office. Comptroller's approval of
contracts let by the Office of General Services is required when such
contracts exceed $30,000 (State Finance Law Section 163.6a).
4. WORKERS' COMPENSATION BENEFITS. In accordance with
Section 142 of the State Finance Law, this contract shall he void and of no
force and effect unless the Contractor shall provide and maintain coverage
during the life of this contract for the benefit of such employees as are
required to be covered by the provisions of the Workers' Compensation
Law.
5. NON-DISCRIMINATION REOUlREMENTS. To the extend
required by Article 15 of the Executive Law (also known as the Human
Rights Law) and all other State and Federal statutory and constitutional
non-discrimination provisions, the Contractor will not discriminate against
any employee or applicant for employment because of race, creed, color,
sex, national origin, sexual orientation, age, disability or marital status.
Furthennore, in accordance with Section 220-e of the Lahor Law, if this is
a contract for the construction, alteration or repair of any public building or
public work or for the manufacture, sale or distribution of materi<:lls,
equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither it
nor its subcontractors shall, by reason ofrace, creed, color, disability, sex,
or national origin: (a) discriminate in hiring against any New York State
citizen who is qualified and available to perform the work; or (b)
discrimina.te against or intimidate any employee hired for the perfonnance
ofwark under this contract. If this is a building service contract as defined
in Section 230 of the Labor Law, then, in accordance with Section 239
May 2003
thereof, Contractor agrees that neither it nor its subcontractors shall by
reason of race, creed, color, national origin, age, sex, or disability: (a)
discriminate in hiring against any New York State citiien who is qualified
and available to perform the work; or (b) discriminate against or intimidate
any employee hired for the performance of work under this contract.
Contractor is subject to fines of$50.00 per person per day for any violation
of Section 220-e or Section 239 as well as possible termination of this
contract and forfeiture of all moneys due hereunder for a second or
subsequent violation.
6 WAGE AND HOURS PROVISIONS. Ifthis is a public work contract
covered by Article 8 of the Labor Law or a building service contract
covered by Article 9 thereof, neither Contractor's employees nor the
employees of its subcontractors may be required or permitted to work more
than the number of hours or days stated in said statutes, except as otherwise
provided in the Labor law and as set forth in prevailing wage and
supplement schedules issued by the State Labor Department. Furthennore,
Contractor and its subcontractors must pay at least the prevailing wage rate
and payor provide the prevailing supplements, including the premium rates
for overtime pay, as determined by the State Labor Department in
accordance with the Labor Law.
7. NON-COLLUSIVE BIDDING REOUIREMENT.In accordance with
Section 139Md of the State Finance Law, if this contract was awarded based
upon the submission of bids, Contractor warrants, under penalty of perjury,
that its bid was arrived at independently and without collusion aimed at
restricting competition. Contractor further warrants that, at the time
Contractor submitted its bid, an authorized and responsible person executed
and delivered to the State a non. collusive bidding certification on
Contractor's behalf.
8. INTERNATIONAL BOYCOTT PROHIBITlON.]n accordance with
Section 220-[ of the Labor Law and Section 139-h of the State Finance
Law, if this contract exceeds $5,000, the Contractor agrees, as a material
condition of the contract, that neither the Contractor nor any substantially
owned or affiliated person, firm, partnership or corporation has participated,
is participating, or shall participate in an international boycott in violation
of the federal Export Administration Act of 1979 (50 USC App. Sections
2401 et seq.) or regulations thereunder. If such Contractor, or any of the
aforesaid affiliates of Contractor, is convicted or is otherwise found to have
violated said laws or regulations upon the final determination of the United
States Commerce Department or any other appropriate agency of the United
States subsequent to the contractors execution, such contract, amendment
or modification thereto shall be rendered forfeit and void. The Contractor
shall so notify the State Comptroller within five (5) business days of such
conviction, determination or disposition of appeal (2NYCRR 105.4).
9. SET-OFF RIGHTS. The State shall have all of its common law,
equitable and statutory rights of setMoff. These rights shall include, but not
be limited to, the State's option to withhold for the purposes of set-off any
moneys due to the Contractor under this contract up to any amounts due and
owing to the State with regard to this contract, any other contract with any
State department or agency, including any contract for a term commencing
prior to the term of this contT<:lct, plus any amounts due and owing to the
State for any other reason including, without limitation, tax delinquencies,
fee delinquencies or monetary penalties relative thereto.
A-2
The State shall exercise its set-off rights in accordance with normal State
practices including, in cases of set.off pursuant to an audit, the finalization
of such audit by the State agency, its representatives, or the State
Comptroller,'
10. RECORDS. The Contractor shall establish and maintain complete and
accurate books, records, documents, accounts and other evidence directly
pertinent to petformance under this contract (hereinafter, collectively, "the
Records"). The Records must be kept for the balance of the calendar year
in which they were made and for six (6) additional years thereafter, The
State Comptroller, the Attorney General and any other person or entity
authorized to conduct an examination, as well as the agency or agencies
involved in this contract, shall have access to the Records during nonnal
business hours at an office of the Contractor within the State of New York
or, if no such office is available, at a mutually agreeable and reasonable
venue within the State, for the term specified above for the purposes of
inspection, auditing and copying. The State shall take reasonable steps to
protect from public disclosure any of the Records which are exempt from
disclosure under Section 87 of the Public Officers Law (the "Statute")
provided that: (1) the Contractor shall timely inform an appropriate State
official, in writing, that said records should not be disclosed; and (ii) said
records shall be sufficiently identified; and (iii) designation of said records
as exempt under the Statute is reasonable. Nothing contained herein shall
diminish, or in any way adversely affect, the State's right to discovery in any
pending or future litigation.
II. IDENTIFYING INFORMATION AND PRIVACY NOTIFICA-
TION. (a) FEDERAL EMPLOYER IDENTIFICATION NUMBER and/or
FEDERAL SOCIAL SECURlTY NUMBER All invoices or New York
State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State
agency must include the payee's identification number, i.e., the seller's or
lessor's identification number. The number is either the payee's Federal
employer identification number or Federal social security number, or both
such numbers when the payee has both such numbers. Failure to include
this number or numbers may delay payment. Where the payee does not have
such number or numbers, the payee, on its invoice or New York State
standard voucher, must give the reason or reasons why the payee does not
have such number or numbers.
(b) PRlV ACY NOTIFICATION. (I) The authority to request the above
personal information from a seller of goods or services or a lessor of real or
personal property, and the authority to maintain such information, is found
in Section 5 of the State Tax Law. Disclosure of this information by the
seller or lessor to the State is mandatory. The principal purpose for which
the information is collected is to enable the State to identify individuals,
businesses and others who have been delinquent in filing tax returns or may
have understated their tax liabilities and to generally identify persons
affected by the taxes administered by the Commissioner of Taxation and
Finance. The information will be used for tax administration purposes and
for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit of the
agency contracting to purchase the goods or services or lease the real or
personal property covered by this contract or lease. The information is
maintained in New York State's Central Accounting System by the Director
of Accounting Operations, Office of the State Comptroller, AESOB,
Albany, New York 12236.
12. EOUAL EMPLOYMENT OPPORTUNITIES FOR MINORITIES
AND WOMEN. In accordance with Section 312 of the Executive Law, if
this contract is: (I) a written agreement or purchase order instrument,
providing for a total expenditure in excess of $25,000.00, whereby a
contracting agency is committed to expend or does expend funds in return
for labor, services, supplies, equipment, materials or any combination of the
foregoing, to be performed for, or rendered or furnished to the contracting
May 2003
agency; or (ii) a written agreement in excess of $1 00,000.00 whereby a
contracting ageney is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or
renovation of real property and improvements thereon; or (iii) a written
agreement in excess of $1 00,000.00 whereby the owner of a State assisted
housing project is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or ren-
ovation ofreal property and improvements thereon for such project, then:
(a) The Contractor will not discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, age,
disability or marital status, and will undertake or continue existing programs
of affirmative action to ensure that minority group members and women are
afforded equal employment opportunities without discrim-ination.
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) at the request of the contracting agency, the Contractor shall request
each employment agency, labor union, or authorized representative of
workers with which it has a collective bargaining or other agreement or
understanding, to furnish a written statement that such employment agency,
labor union or representative will not discriminate on the basis of race,
creed, color, national origin, sex, age, disability or marital status and that
such union or representative will affirmatively cooperate in the
implementation of the contractor's obligations herein; and
c) the Contractor shall state, in all solicitations or advertisements for
employees, . that, in the performance of the State contract, all qualified
applicants will be afforded equal employment opportunities without dis.
crimination because of race, creed, color, national origin, sex, age, disability
or marital status.
Contractor will include the provisions of "a, lib", and "c" above, in every
subcontract over $25,000.00 for the construction, demolition, replacement,
major repair, renovation, planning or design of real property and
improvements thereon (the "Work") except where the Work is for the
beneficial use of the Contractor. Section 312 does not apply to: (I) work,
goods or services unrelated to this contract; or(ii) employment outside New
York State; or (iii) banking services, insurance policies or the sale of
securities. The State shall consider compliance by a contractor or
subcontractor with the requirements of any federal law concerning equal
employment opportunity which effectuates the purpose of this section. The
contracting agency shall determine whether the imposition of the
requirements of the provisions hereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Section 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful
rules and regulations of the Governor's Office of Minority and Women's
Business Development pertaining hereto.
13. CONFLICTING TERMS. In the event of a conflict between the
terms of the contract (including any and all attachments thereto and
amendments thereof) and the terms of this Appendix A, the tenns of this
Appendix A shall control.
14. GOVERNING LA W This contract shall be governed by the laws of
the State of New York except where the Federal supremacy clause requires
otherwise.
A-3
15. LATE PAYMENT. Timeliness of payment and any interest to be paid
to Contractor for late payment shall be governed by Article ll-A of the
State Finance Law to the extent required by law.
16. NO ARBITRATION. Disputes involving this contract, including the
breach or alleged breach thereof, may not be submitted to binding
arbitration (except where statutorily authorized), but must, instead, be heard
in a court of competent jurisdiction of the State of New York.
17. SERVICE OF PROCESS. In addition to the methods of service
allowed by the State Civil Practice Law & Rules ("CPLR"), Contractor
hereby consents to service of process upon it by registered or certified mail,
return receipt requested. Service hereunder shall be complete upon
Contractor's actual receipt of process or upon the State's receipt of the
return thereof by the United States Postal Service as refused or
undeliverable. Contractor must promptly notify the State, in writing, of each
and every change of address to which service of process can be made.
Service by the State to the last known address shall be sufficient. Contractor
will have thirty (30) calendar days after service hereunder is complete in
which to respond.
18. PROHIBITION ON PURCHASE OF TROPICAL HARD-
WOODS. The Contractor certifies and warrants that all- wood products to
be used under this contract award will be in accordance with, but not
limited to, the specifications and provisions of State Finance Law 9165,
(Use of Tropical Hardwoods) which prohibits purchase and use of tropical
hardwoods, unless specifically exempted, by the State or any governmental
agency or political subdivision orpub]ic benefit corporation. Qualification
for an exemption under this law will be the responsibility of the contractor
to establish to meet with the approval of the State.
In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be penonned by any subcontractor, the
prime Contractor wil] indicate and certify in the submitted bid proposal that
the subcontractor has been inforrned and is in compliance with
specifications and provisions regarding use of tropical hardwoods as
detailed in 9165 State Finance Law. Any such use must meet with the
approval of the State, otherwise, the bid may not be considered responsive.
Under bidder certifications, proof of qualification for exemption will be the
responsibility of the Contractor to meet with the approval of the State.
19. MACBRIDE FAIR EMPLOYMENT PRINCIPLES. In accordance
with the MacBride Fair Employment Principles (Chapter 807 of the Laws
of] 992), the Contractor hereby stipulates that the Contractor either (a) has
no business operations in Northern Ire]and, or (b) shall take lawful steps in
good faith to conduct any business operations in Northern Ireland in
accordance with the MacBride Fair Emp]oyment Principles (as described
in Section 165 of the New York State Finance Law), and shall permit
independent monitoring of compliance with such principles.
20. OMNIBUS PROCUREMENT ACT OF 1992. It is the policy of New
York State to maximize opportunities for the participation of New York
State business enterprises, including minority and women-owned business
enterprises as bidders, subcontractors and suppliers on its procurement
contracts.
Infonnation on the availability of New York State subcontractors and
suppliers is available from:
NYS Department of Economic Development
Division for Small Business
30 South Pearl Street, 7lh floor
Albany, New York 12245
518-292-5220
May 2003
A directory of certified minority and women-owned business enterprises
is available from:
NYS Department of Economic Development
Minority and Women's Business Development Division
30 South Pearl Street, 2"" floor
Albany, New York 12245
http://www.empire.state.ny.us
The Omnibus Procurement Act of ] 992 requires that by signing this bid
proposal or contract, as applicable, Contractors certify that whenever the
total bid amount is greater than $] million:
(a) The Contractor has made reasonable efforts to encourage the
participation of New York State Business Enterprises as suppliers and
subcontractors, including certified minority and women-owned business
enterprises, on this project, and has retained the documentation of these
efforts to be provided upon request to the State;
(b) The Contractor has complied with the Federal Equal Opportunity Act
of 1972 (Pol. 92-261), as amended;
@) The Contractor agrees to make reasonable efforts to provide
notification to New York State residents of employment opportunities on
this project through listing any such positions with the Job Service
Division of the New York State Department of Labor, or providing such
notification in such m~ner as is consistent with existing collective
bargaining contracts or agreements. The Contractor agrees to document
these efforts and to provide said documentation to the State upon request;
and
(d) The Contractor acknowledges notice that the State may seek to obtain
offset credits from foreign countries as a result of this contract and agrees
to cooperate with the State in these efforts.
21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are
hereby notified that if their principal place of business is located in a
country, nation, province, state or political subdivision that penalizes New
York State vendors, and if the goods or services they offer will be
substantially produced orperfonned outside New York State, the Omnibus
Procurement Act 1994 amendments and 2000 amendments (Chapter 684
and Chapter 383 respectively) require that they be denied contracts which
they would otherwise obtain. NOTE: As of May 15,2002, the list of
discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii.
Contact NYS Department of Economic Development for a current list of
jurisdictions subject to this provision.
22. PURCHASES OF APPAREL. In accordance with Stale Finance
Law 162 (4-a), the State shall not purchase any apparel from any vendor
unable or unwilling to certify that: (I) such apparel was manufactured in
compliance with all applicable labor and occupational safety laws,
including, but not limited to, child labor Jaws, wage and hours laws and
workplace safety laws, and (ii) vendor will supply, with its bid (or, if not
a bid situation, prior to or at the time of signing a contract with the State),
if known, the names and addresses of each subcontractor and a list of all
manufacturing plants to be utilized by the bidder.
Al-l
APPENDIX Al
Agency-Specific Clauses
I. General
A. For the purposes of this Agreement, the terms "State" and "Department" are
inter-changeable, unless the context requires otherwise.
B. The Contract Period as set forth on the Face Page is the inclusive period
within which the provisions of this Agreement shall be performed. Costs
incurred for project activities conducted prior to or after the Contract Period
will not be reimbursed under this Agreement.
C. The Contractor and Project (as described in the Legislative Initiative Form
provided to the Contractor by the Department and incorporated herein by
references and as detailed in the Program Workplan, Appendix D) have been
identified to the Department for receipt of a local grant award not to exceed
the Funding Amount as set forth on the Contract Face Page.
D. The Department shall not be liable for expenses of any kind incurred in
excess of the Funding Amount, and shall not be responsible for seeking
additional appropriations or other sources of funds for the Project.
E. The Contractor shall perform all services to the satisfaction of the
Department. The Contractor shall provide all services and meet the program
objectives set forth in Appendix D in accordance with: provisions of this
Agreement; relevant laws, rules and regulations, administrative and fiscal
guidelines; and where applicable, operating certificates for facilities or
licenses for an activity or program.
F. Pursuant to the provisions set forth in Section V., page 3 of this Agreement,
the ownership of all property described therein shall reside with the
Contractor unless otherwise specified in writing by the Department at
anytime during the term of this Agreement and up to thirty (30) days
following the issuance of the final payment.
AI-2
II. Funding
A. Funding for this project has been appropriated in the Community Projects
Fund as established by Section 99-d of the State Finance Law (Chapter 474
ofthe Laws of 1996). Pursuant to Paragraph 6(a) of Section 99-d, "The state
shall not be liable for payments pursuant to any contract, grant or agreement
made pursuant to an appropriation in any account of this fund if insufficient
monies are available for transfer to such account of this fund, after required
transfers pursuant to subdivision three of this section."
B. Notwithstanding the Contract Period set forth on the Face Page, absent
reappropriation in the subsequent State budget, funds for this project will
cease to be available for payments on September 15,2007; in that event, to
afford reasonable assurance that payment can be made by the Department,
final payment requests must be received by the Department's payment office
by not later than August 20, 2007.
III. Terminations
A. In addition to any other actions authorized by this Agreement, the
Department may terminate the Agreement in the best interests ofthe State of
New York by providing written notice to the Contractor as provided in this
Agreement.
B. The Contractor shall complete the project as set forth in this Agreement, and
failure to render satisfactory progress or to complete the project to the
satisfaction of the State may be deemed an abandonment of the project and
may cause the suspension or termination of any obligation ofthe State. In the
event the Contractor should be deemed to have abandoned the project fo any
reason or cause other than a national emergency or an Act of God, all monies
paid to the Contractor by the State and not expended in accordance with this
Agreement shall be repaid to the State upon demand. Ifsuch monies are not
repaid within one year after such demand, the State Comptroller of the State
of New York may cause to be withheld from any State assistance to which the
Contractor would otherwise be entitled an amount equal to the monies
demanded.
AI-3
C. In the event that the Department has provided written notice to the Contractor
directing that the Contractor correct any failure to comply with this
Agreement, the Department reserves the right to direct that the Contractor
suspend all work during a period of time to be determined by the Department.
If the Contractor does not correct such failures during the period provided for
in the notice, this Agreement shall be deemed to be terminated after
expiration of such time period. During any such suspension, the Contractor
agrees not to incur any new obligations after receipt of the notice without
approval by the Department.
IV. Vendor (Contractor) Responsibility
A. The Department is required to conduct a review of a prospective contractor
to provide reasonable assurance that the contractor is responsible. To be
considered responsible a contractor should have appropriate legal authority
to do business in New York State, a satisfactory record of integrity,
appropriate financial, organizational and operational capacity and controls
and acceptable performance on previous governmental contracts, if any. The
State and any of it's agencies may use information gathered from whatever
resources it deems appropriate to assist in making a responsibility
determination.
B. If the prospective contractor is a non-governmental entity and this contract
has a total value in excess of $15,000 in state-provided funds a Vendor
Responsibility Questionnaire, with certification is included with the contract
package. This Questionnaire is designed to provide information to assist the
contracting agency in assessing a contractor's responsibility prior to entering
into a contract and must be completed and returned with the contract.
C. Contractor hereby acknowledges that, where required, the Vendor
Responsibility Questionnaire and certification is made a part of this contract
by reference hereto and that any misrepresentation of fact in the
Questionnaire and attachments, or in any contractor responsibility
information that may be requested by the Department, may result in
termination of this contract. During the term of this Contract, any changes in
the information provided in the Questionnaire shall be disclosed to the
Department, in writing, in a timely manner. Failure to make such disclosure
may result in a determination of non-responsibility and termination of the
contract.
Al-4
D. Should it be determined at any time that a contractor is not responsible,
the Department will notify the contractor in writing setting forth the basis
for the determination and affording the contractor reasonable time in
which to refute the determination, justify why the basis for the
determination is not relevant to this contract or to take corrective action
to eliminate the responsibility impediment. lfthe responsibility condition
cannot be reconciled to the satisfaction of the Department and the State
the contract, or contract offer will be terminated by written notification.
V. Fully-Executed Agreement or Amendment Thereto
A. If this Agreement, or amendments thereto, allocates funds totaling $15,000
or less, it shall be deemed to be fully executed when approved and signed by
the Contractor and the Department.
B. If this Agreement, or amendments thereto, allocates funds totaling more than
$ I 5,000, it shall be deemed to be fully executed when approved by the Office
of the State Comptroller.
Attachment I to Appendix A I
Article lS-A ofthe New York State Executive Law
The Department of State administers a Minority and Women-owned Business
Enterprises (MWBE) Program as mandated by Article 15-A of the New York State
Executive Law. This law supersedes any other provision in state law authorizing or
requiring an equal employment opportunity program or a program for securing
participation by minority and women-owned business enterprises. Under this law, all
state agencies must, subject to certain exceptions, establish goals for minority and
women-owned business participation in certain state contracts and grants. Where
MWBE goals are required, even in circumstances where this goal is zero, a Quarterly
Grantee Report is required to be submitted to the Affirmative Action Office of the
Department on forms provided by the Department.
Article 15-A requires that rules and regulations be established for contracts
entered into by the Department. In accordance with Article 15-A, goals must be set
for contracts entered into by the Department in excess of$25,000 for labor, services,
supplies, equipment, and materials, or any combination of the foregoing, and for
contracts entered into by the Department in excess of $100,000 for acquisition,
construction, demolition, replacement, major repair, renovation or improvement of
real property. In applying these rules and regulations, the Department must consider
the availability of certified minority and women-owned businesses in the region in
which the state contract will be performed, the total dollar value of the Contract, the
scope of work to be performed, and the project size and term.
The contractor will, when required as a part of the bid or proposal, submit a
Staffing Plan on the form provided by the Department. This Plan will detail the work
force anticipated in the performance of the state contract broken down by ethnic
background, gender, and Federal Occupational Categories.
After a bid opening and prior to the award of a state contract, the contractor will
submit an Equal Employment Opportunity (EEO) Policy Statement to the Department
within the time frame established by the Department. The law requires that, as a
precondition to entering into a valid and binding state contract, the contractor shall
agree to the following stipulations and will include them in the EEO Policy
Statement:
. The contractor will not discriminate against any employee or applicant
for employment because of race, creed, color, national origin, sex, age,
disability or marital status.
. The contractor will undertake or continue eXlstmg programs of
affirmative action to ensure that minority group members and women are
afforded equal employment opportunities without discrimination because
of race, creed, color, national origin, sex, age, disability or marital status.
For these purposes, affirmative action applies in areas of recruitment,
employment, job assignment, promotion, upgrading, demotion, transfer,
layoff, or termination and rates of payor other forms of compensation.
. The contractor will make active and conscientious efforts to employ and
to utilize minority group members and women at all levels and in all
segments of its work force on state contracts, and the contractor will
document these efforts.
. The contractor will state in all solicitations and advertisements for
employees that, in the performance of the state contract, all qualified
applicants will be afforded equal employment opportunities without
discrimination because of race, creed, color, national origin, sex, age,
disability or marital status.
. The contractor will, at the request of the Department, request each
employment agency, labor union, or authorized representative of workers
at which it has a collective bargaining or other agreement or understanding,
to furnish a written statement that such employment agency, labor union,
or representative will not discriminate because of race, creed, color,
national origin, sex, age, disability or marital status, and that such union or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein.
. The contractor will include the provisions regarding the EEO Policy
Statement and the Staffing Plan enumerated above in each and every
subcontract of a state contract in such a manner that the subcontractor is
bound by these requirements.
. Failure to provide an EEO Policy Statement and a Staffing Plan without
reasonable written justification or commitment to provide these
requirements by a specified date will result in rejection of the contractor's
bid or proposal.
. After the award of a state contract, the contractor will submit to the
Department a Work Force Employment Utilization Report, on the form
supplied by the Department, detailing the work force actually utilized on
the state contract, by ethnic background, gender and Federal Occupational
Categories, as specified on the form. This Report will be submitted to the
Department on a quarterly basis throughout the life of the contract.
. The contractor, and any of its subcontractors, may be required to submit
compliance reports relating to their operations and implementation oftheir
affirmative action or equal employment opportunity program in effect as of
the date the state contract is executed.
Questions regarding this program should be directed to the New York State
Department of State's Affirmative Action Office, 41 State Street, Albany, New York
12231,518-474-2752. To assist potential contractors, a copy of the NYS Directory
of Certified Minority and Women-owned Business Enterprises is made available for
inspection at the Department's Affirmative Action Office. The Department makes
no representation with respect to the availability or capability of any business listed
in the Directory.
B-1
APPENDIX B
Budget
Budget Summary Sheet
A. SALARIES, WAGES AND FRINGE $
B. TRAVEL $
C. SUPPLIES/MA TERIALS $
D. EQUIPMENT $r. 000. 00
E. CONTRACTUAL SERVICES $9.000.00
F. OTHER $
TOTAL $10,000.00
The TOTAL of your BUDGET must equal the amount of your allocation as shown
on the CONTRACT FACE PAGE!
The BUDGET is intended to show the items of expense which will be funded under
this Contract. Please do not show the entire cost of the project if it exceeds the
amount of funding provided by this Contract.
Questions regarding Budget preparation? Call 518-486-3905
B-2
Budget Detail Sheet
A. SALARIES. WAGES AND FRINGE
Amount Charged
Title to this Proiect
TOTAL SALARIES, WAGES AND FRINGE $
B. TRAVEL
Please indicate destination, purpose and cost of such travel.
TOTAL TRAVEL
$
Budget Detail Sheet
B-3
C. SUPPLIES/MATERIALS
Please use general categories such as office supplies, printing supplies, small tools, building
materials and like category descriptions. Indicate the cost of each category.
TOTAL SUPPLIES/MA TERIALS
$
D. EQUIPMENT
Please list each item of equipment that exceeds $200.00 per item and has a useful life
of one year or more. Group items of less than $200.00 each into general categories
indicating total cost per category.
41 air mattresses for special needs shelter
TOTAL EQUIPMENT
$1,000.00
Budget Detail Sheet
B-4
E. CONTRACTUAL SERVICES
This category includes items such as telephone, postage, rent, utilities, rental or repairs to
equipment, lease of equipment, contracted services and contracted construction costs.
printing educational outreach materials
postage
TOTAL CONTRACTUAL SERVICES
$9,000.00
F. OTHER
Please specify what these costs are.
TOTAL OTHER
$
c-!
APPENDIX C
Payment and Reporting Schedule
l. This is a cost reimbursement Agreement. The Contractor may claim and be
reimbursed for eligible project costs incurred (costs of eligible project activities
conducted, and goods and services received and accepted by the Contractor)
within the Contract Period. The total of such reimbursement shall not exceed the
Funding Amount for this Agreement and shall be claimed by the Contractor in
accordance with the payment option selected below.
PAYMENT OPTIONS: Circle the option to be applied to this agreement.
Example: Option A
Option A: Payment-In-Full For Completed Project
1. In the event that the project has been completed and all eligible project costs
incurred within the Contract Period and prior to the submission of this
Agreement to the Department for execution, the Contractor may request a
one-time payment-in-full with the submission of the Agreement.
2. Complete the contract documents in accordance with the instructions, making
sure that the contract budget categories add up to the total Funding Amount
regardless ofthe total costs to be claimed. Ifthe total costs to be claimed are
less than the Funding Amount, the claim on the Standard Voucher (AA.
below) will reflect actual expenditures.
3. Complete the Program Workplan (Appendix D) making sure it accurately
describes the project activities completed and the dates of completion. If
the project was on-going in nature, specify the time- frame (start and end
dates) that costs were incurred. Ifthe project was for equipment, supplies or
commodities purchases, specify the delivery date(s) of the item(s)
purchased.
4. Complete the Standard Voucher received with the contract documents in
accordance with the instructions, with the exception of Section 6. Put the
following statement in Section 6:
"Requesting payment-in-full for eligible project costs
incurred pursuant to all terms and conditions of Contract
#(insert contract number) submitted herewith."
C-2
5. Submit the completed contract documents and voucher claiming payment-in-
full in accordance with the instructions. Upon full execution of the
Agreement, payment will be made pursuant to the schedule set forth in II.
below, and a copy of the fully-executed Agreement will be sent to you for
your records.
Option B: Periodic Progress Payments
I. Contractor may request periodic progress payments for eligible project costs
incurred following full execution of the Agreement by both parties.
2. Complete the contract documents and submit them to the Department in
accordance with the instructions. Do not submit a voucher or other payment
documents at this time.
3. Upon full execution, a copy of the fully-executed Agreement and payment
request documents and instructions for claiming progress payments will be
sent to you.
4. Reimbursement for eligible project costs incurred will be made upon receipt
and approval of properly completed payment requests submitted in
accordance with III. below.
Option C: Advance and Progress Payment(s)
I. Contractor may request an advance equal to twenty-five percent (25%) ofthe
Funding Amount.
2. Complete the contract documents in accordance with the instructions.
Complete the Standard Voucher in accordance with the instructions inserting
the statement "25 percent advance" in Section 6. Submit the completed
contract documents and advance voucher to the Department in accordance
with the instructions.
3. Upon full execution of the Agreement, the advance will be issued in
accordance with the schedule set forth in II. below and a copy of the fully-
executed Agreement and payment request documents and instructions for
claiming progress payments will be sent to you.
C-3
4. Upon receipt of a progress payment request submitted in accordance with III.
below, the Department will determine the total eligible costs, deduct 25
percent of that amount to document advance funds received, and pay the
balance to the Contractor.
5. Upon termination ofthis contract, the full amount of undocumented advance
funds shall become immediately due and owing to the Department.
II. The payment-in-full provided for in I.A. above or the advance provided for in
I.c. above will be paid by no later than December 14,2006.
In the event that the Department does not receive a properly completed contract
package from the Contractor by October 13, 2006, the payment date will be
recalculated to be no later than sixty (60) days following receipt of the properly
completed contract package.
III. Progress payment requests as provided for in I.B. and I.C. above shall be
submitted to the Department's designated payment office at the following
address:
New York State Department of State
Contract Administration Unit - LMI
41 State Street / 10th Floor
Albany, New York 12231-0001
A. Payments shall be made to the Contractor upon the submission by the
Contractor of properly executed progress payment requests. Each such
request shall contain the following: (1) "Summary Sheet Documentation
Forms" as provided by the Department, for documentation of actual and
eligible expenditures; (2) a narrative progress report describing in detail all
significant project accomplishments for which reimbursement is claimed,
with dates of completion (NOTE: If this agreement is for the purchase of
tangible goods, commodities or equipment only, a narrative is not
required for payments; however, a listing of all items purchased and
dates received must be detailed on the Summary Sheet Documentation
Forms.); and (3) a properly completed Standard Voucher.
B. Notwithstanding the above requirements, upon written notification by the
Department, the Contractor may be required to submit source documentation
and additional verification of allowable expenditures.
C-4
C. Payment requests as described in I1LA. above shall be certified by a duly
authorized representative of the Contractor as accurately representing such
accomplishments and expenses as recorded in the Contractor's accounting
records, including, where goods or services are provided by third parties not
party to this Agreement, a certification that any payment obligations arising
from the provision of such goods or services have been paid by the
Contractor and do not duplicate reimbursement or costs and services received
from other sources.
D. Claimed expenditures per cost category may exceed the amounts indicated
in the Budget, Appendix B, by ten percent (10%) or $1,000, whichever is
greater, without approval of the Department, provided that the Funding
Amount is not exceeded. Any expenditure in excess of such 10% or $1,000
shall require an amendment to the Project Budget submitted in writing by the
Contractor. No expenditures shall be allowed for items not set forth in the
Project Budget without prior written approval of the Department.
E. Any payment request for any period during which all Project activities shall
have been completed shall be submitted as the Contractor's final payment
request and shall be clearly labeled FINAL.
I. If a final progress narrative report is required to be submitted, it must
describe in reasonable detail, the nature and degree of the Project's
completion and results.
2. If the Contractor has received prior payments exceeding total eligible
expenditures, Contractor shall remit such excess to the Department with
such FINAL request.
IV. Notwithstanding the submission of timely and properly executed payment
requests, the Department shall be under no obligation to make payment for
expenditures incurred without the prior Department approvals and/or
amendments required under this Agreement and, further, shall have the right to
withhold any such payment pending the execution of such approval and/or
amendment.
A. Interest income earned on funds received pursuant to this Agreement shall be
used to further the purpose of this Project or shall be deducted from total
eligible costs to determine the net eligible costs to be reimbursed by the
Department.
C-5
B. The Department shall have the right to conduct on-site progress assessments
and reviews ofthe Project and Contractor's books and records during the life
ofthis Agreement and for a reasonable time following issuance ofthe FINAL
payment.
C. The Department shall be entitled to disallow any cost or expense, or
terminate or suspend this Agreement, if found that the Contractor has
misrepresented any expenditures or Project activities in this Agreement, or
in any progress reports or payment requests made pursuant hereto.
D. The Contractor shall maintain separate fiscal books and records for all funds
received through the Department and Project activities conducted pursuant
to this Agreement, and shall make all such books and records available to the
Department, the Office of the State Comptroller, or their designated
representatives for inspection and audit for a period of six (6) years following
termination of this Agreement.
D-1
APPENDIX D
Program W orkplan
Town of Southold
Type: Leg. Initi tive
Program Contact Person:
Russell
Daytime Phone:
Fax:
(631) 765-1889
( 631) 765-1823
NARRA TIVE
(MUST BE COMPLETED FOR ALL PROJECT TYPES AND PAYMENT OPTIONS)
NOTE: If payment Option A: Payment-In-Full for completed project was selected, make sure that
this Narrative complies with Section 3 of Option A.
Printing/postage for direct mail instructional/education
brochure re: emergency information.
Printing of color booklet for distribution about hurricanes/
coastal storms, preparation and sheltering.
(ATTACH ADDITIONAL PAGES AS NEEDED)
E-l
APPENDIX E
CHARITIES AND CHARITABLE TRUSTS
Most not-for-profit organizations (including corporations and charitable trusts) are
required to file annual financial reports with the Attorney General. This requirement is
found in Article 7-A of the Executive Law and Article 8 of the Estates, Powers and
Trusts Law (EPTL). Specifically, Section 8-1.4 of the EPTL states:
(a) For the purposes of this section, "trustee" means (I) any individual, group of
individuals, corporation or other legal entity holding and administering property for
charitable purposes, whether pursuant to any will, other instrument or agreement, court
appointment, or otherwise pursuant to law, over which the attorney general has
enforcement or supervisory powers, (2) any non-profit corporation organized under the
laws of this state for charitable purposes, and (3) any non-profit foreign corporation
organized for charitable purposes, doing business or holding property in this state.
Neither a foreign corporation nor a trustee acting under the will of, or any agreement
executed by, a non-resident of this state shall become subject to the provisions of this
section merely by reason of maintaining a bank, custody, investment or similar account
in this state.
(s) A trustee shall not be qualified to make application for funds or grants or to receive
such funds from any department or agency ofthe state without certifYing compliance
with paragraphs (d), (t), and (g) of this section and all applicable registration and
reporting requirements of Article 7 -A of the Executive Law.
In addition, please note that the new Charities Registration number is a 6-digit number
with a hyphen after the second and fourth digits.
Pages E-2 and E-3 contain the inclusive listing of exemptions to the registration and
reporting requirements of each article of law cited above.
If the Contractor qualifies for exemption from ei ther article of law, place the complete
number, i.e., 2(b), of the exemption in the respective section of Box 4 on the Contract
Face Page.
Any questions regarding the statutory requirements or applicability to your organization
should be directed to:
Office of the Attorney General
Charities Registration Bureau
] 20 Broadway
New York, New York ]0271
2] 2-4] 6-8400/ 2] 2-4] 6-840 I
E-2
CHARITIES REGISTRATION EXItMPTIONS
EXECUTIVE LAW, ARTICLE 7-A
I. This article shall not apply to corporations organized under the religious corporations law, and other
religious agencies and organizations, and charities, agencies, and organizations operated, supervised, or controlled by
or in connection with a religious organization.
2. The following persons shall not be required to register with the attorney general:
(a) An educational institution confining its solicitation of contributions to its student body, alumni, faculty and
trustees, and their families.
(b) Fraternal, patriotic, social, alumni, law enforcement support organizations and historical societies chartered
by the New York state board of regents when solicitation of contributions is confined to their membership.
@) Persons requesting any contributions for the relief of any individual, specified by name at the time of
solicitation, if all ofthe contributions collected, without any deductions whatsoever, are paid to or for the benefit ofthe
named beneficiary.
(d) Any charitable organization which does not intend to solicit and receive and does not actually receive
contributions in excess of twenty-five thousand dollars during a fiscal year of such organization, provided none ofits
fund raising functions are carried on by professional fund raisers or commercial co-venturers. However, ifthe gross
contributions received by such charitable organization during any fiscal year of such organization shall be in excess of
twenty-five thousand dollars, it shall within thirty days after the date it shall have received total contributions in excess
of twenty-five thousand dollars register with the secretary as required by section one hundred seventy-two of this article.
(e) Any charitable organization receiving an allocation from a federated fund, incorporated community appeal
or a united way, provided such fund, appeal or united way is complying with the provisions ofthis article relating to
registration and filing of annual reports with the secretary, and provided such organization does not actually receive,
in addition to such allocation, contributions in excess of twenty-five thousand dollars during the fiscal year, and
provided further that all the fund-raising functions of such organizations are carried on by persons who are unpaid for
such services. However, ifthe gross contributions other than such allocation received by such charitable organization
during any fiscal year of such organization shall be in excess oftwenty-five thousand dollars, it shall within thirty days
after the date it shall have received such contributions in excess of twenty-five thousand dollars register with the
secretary as required by section one hundred seventy-two of this article.
(f) A local post, camp, chapter or similarly designated element, or a county unit of such elements, of a bona
fide veterans' organization which issues charters to such local elements throughout this state, a bona fide organization
of volunteer firemen, an organization providing volunteer ambulance service (as defmed in section three thousand one
ofthe public health law) or a bona fide auxiliary or affiliate of such organizations, provided all its fund-raising activities
are carried on by members of such an organization or an affiliate thereof and such members receive no compensation,
directly or indirectly, thereof.
(g) An educational institution which files annual financial reports with the regents oftheuniversity of the state
of New York as required by the education law or with an agency having similar jurisdiction in another state or library
which files annual financial reports as required by the state education department.
(h) A charitable organization which receives all or substantially all of its funds from a single governmental
agency and reports annually to that agency provided such reports contain financial information substantially similar in
content to that required by subdivision one of section one hundred seventy-two-b of this article; provided, however, that
such organization may receive no more than twenty-five thousand dollars from sources other than the government
agency to which it reports.
(I) Any police department, sheriffs department or other governmental law enforcement agency.
Ul The state parent teachers association and any parent teachers association affiliated with an educational
institution that is subject to the jurisdiction of the state education department.
3. In addition to the statutory exemptions, the following are also exempt:
(a) Any Municipality.
(b) Fire Districts, School Districts, and Water Districts.
E-3
CHARITABLE TRUSTS REPORTING EXEMPTIONS
ESTATES, POWERS AND TRUSTS LAWS
EXECUTIVE LAW, ARTICLE 8, SECTION 8-1.4(b)
The registration and reporting provisions of this section do not apply to:
I. Contractor is not a Trustee as define in Section 8-1.4(a) set forth in Appendix E.
2. Government entity
3. Entity required by law to complete an annual report to either the United States Congress or the
New York State Legislature;
4. Religious organizations;
5. Educational institution incorporated under the Education Law or by special act;
6. Hospital;
7. Fraternal, patnotIc, social, student, alumni, veterans, volunteer firefighters, volunteer
ambulance workers' organization or historical society chartered by the New York State Board
of Regents;
8. Trust or estate for which there is a corporate trustee acting as sole trustee or co-trustee under
the will of a decedent who died domiciled outside New York or a trust instrument executed by
a nonresident of New York State;
9. Trust or estate in which the charitable interest is delayed or contingent;
10. Officer, director or trustee of an organization exempt from registration who holds property for
the religious, educational or charitable purposes of the organization;
II. Cemetery corporation subject to the provisions of Article 15 of the Not-for-Profit Corporation
Law;
12. The state parent teachers association CPT A") and any parent teachers association affiliated with
an educational institutional that is subject to the jurisdiction ofthe State Education Department;
and
13. Any corporation organized under Article 43 of the Insurance Law.
APPENDIX X
Agency Code
Contract Period
Contract Number
Funding for Period
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the New York State
Department of State, having its principal office in Albany, New York (hereinafter referred to as the STATE), and
(hereinafter referred to as the CONTRACTOR), for modification of Contract
Number , as amended above.
All other provisions of said AGREEMENT shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under
their signatures.
CONTRACTOR SIGNATURE
By:
STATE AGENCY SIGNATURE
By:
(print name)
(print name)
Title: Title:
Date: Date:
State Agencv Certification: "In addition to the acceptance of this Contract, I also certify that original copies of this signature
page will be attached to all other exact copies of this Contract."
STATE OF NEW YORK )
COUNTY OF ) ss:
On this _ day of , in the year 20_, before me personally appeared
, to me known, who, being by me duly sworn, did depose and say
that (s)he resides at ; that (s)he is the
~ ,llie
corporation described herein which executed the foregoing instrument; and that (s)he signed (her)his name thereto
by order of the board of directors of said corporation.
NOTARY PUBLIC
STATE OF NEW YORK )
COUNTY OF ) ss:
On this _ day of , in the year 20_, before me personally appeared
, to me known and known to me to be the
~ ,~
unincorporated association described in and which executed the above agreement; and who acknowledge to me that
(s)he executed the foregoing agreement for and in behalf of said unincorporated association.
NOTARY PUBLIC
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
AC 92 (Rev. 6!9~1
;:Jcr:: 11'4';:)' nv\..rI IVI't;:J VI'l1 nl:. V I:. n;) I:. ;)IUI:. DCrVnl:. \.oVIVII""'Lr:.I 1I'4\.:l1
OF Voucher No.
NEW YORK
~ Originating Agency 10"9. Agency Code Interest Eligible (Y IN) t-;:/5-(D 11
Payment Date IMM) (00) (YY) lose Use Only liability Date (MMI IDOl IYYI
I I I I
~ Payee 10 Additional I lip Code I Route Payee Amount I MIR Dale IMM) (DO) IYY)
,{- inDO r<i:J'=t I I
:U Payee Name (Limit to 30 spaces) IRS Code IRS Amount
Town of Southold
Payee Name (Limit to 30 spaces} Stat. Type Statistic Indicator-Dept. Ilndicator-St8leWide
Address (Limit 10 30 spaces) ^-cf iJ Ref/lnv. No. (Limit to 20 spaces)
<'5D9S- 1vIct-'c1'\
Ap;ectitf?~es) l (1 y Rel/lnv. Date (MM) (00) IYYI
I I
C}~::+-h~) ( rI (Limil 102 spaces) ~ wrl ZIP(CCd?1 (-07J1
~ Purchase Description at MalefiallService
Order No If items are too numerous to be incorporated into lhe block below, Quantity Unit Price Amount
and Date use Form AC 93 and carry total forward.
5p V'a( ;u~jJ Jt (0) 000. X
~ ~Jq\C r I
I
I
I
I
I
I
I
I
I
~ Payee cert'flCali~
I certify lhal the above bll I ust, true and correct, that no part thereof has been paid except as stated and that Total
the balance IS actuall and owmg, d that taxe;;om which the State IS exempt are excluded Discount
~ !_ I I ~l1p""'''''''Ti ,:;::nr
'j / . j V Payee's Signature In Ink TJ\le %
h ./ /1/ /{,:y.- 'T't""\t.TYl '"' ~ c::.t""\"t-nt""\' rI
Date Name 01 Company
Net
FOR AGENCY USE ONLY STATE COMPTROLLER'S PRE-AUDIT
Merchandise Received I certify that this vOuCher is correct and just, and payment is approved, and the goods or sef'llices Cel1ilied For Payment
rendered or furnished are fcruse in the performance olfhe official tunctions and duties of Ihis 01
agency Verified Net Amount
Date
Authorized Signature Audited
Page No
B, Date Title SpeciatApproval By
(as Required)
Expenditure LlquldatlDn
Cost Center Code Accum
Dept. Cost Center Unit Va' y, Object Amount Orig. Agency PO/Contract Line FIP
Dept. Statewide
I
:
i
STATE
STANDARD VOUCHER
o
Check if Continuation
lorm is attached.
OSC
CONTRACT FACE PAGE
STATE AGENCY
New York State Department of State
41 State Street
Albany, New York 12231
BOX 1 - CONTRACTOR (Name and Business Address)
Town ofSouthhold
53095 Main Road
P.O. Box 1179
Southo1d, NY 11971-0959
BOX 2 - FEDERAL TAX ID NUMBER
116001939
I ~~ICI~AL~~E#
", 'I
',t.,:_"),};:".".,,
"'':::,:::'.>~r:..''''''::,,:::':
BOX 3 - STATUS
Sectarian entity?
Not-for-profit organization?
Yes_Noi(.
Yes No x
'FiQ])~:~$1~wt\:"
,:t:,~~W'
BOX 4 - CHARITIES REGISTRATION NUMBER _NLl! - _ _ - _ _ / EXEMPTION (E-2) - __
EST A TES, POWERS AND TRUSTS LAWS REPORTING EXEMPTION (E-3) -
BOX 5 - If you did not claim an exemption to both ofthe items in Box 4, you must check the applicable
response in the following: N/A
Contractor has _ / has not ~ timely filed with the Attorney General's Charities Bureau all required
periodic or annual written reports.
APPENDICES A TT ACHED TO AND PART OF THIS AGREEMENT
APPENDIX A:
APPENDIX AI:
APPENDIX B:
APPENDIX C:
APPENDIX D:
APPENDIX E:
APPENDIX X:
Standard Clauses as Required by the Attorney General for all State Contracts
Agency-specific Clauses
Budget
Payment and Reporting Schedule
Program Workplan
Charities Bureau Registration and Reporting Exemptions
Modification Agreement Form (to accompany modified appendices for changes in term or
consideration on an existing period or for renewal periods)
2005-2006 LMI
SIGNATURE PAGE
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below
their signatures.
CONTRACT #M051096
CONTRACTOR
Town of Southold
STATE AGENCY
New York State Department of State
By:
By:
~AI'1?~
.c:~nt-r :no. 'Rll~.c:p.l1
(Print Name)
(Print Name)
Title:
Date:
Title: Supervi sor
Date: f?~C
State Agencv Certification
"In addition to the acceptance of this Contract, I also certify
that original copies of this signature page will be attached
to all other exact copies of this Contract."
STATE OF NEW YORK)
COUNTY OFsUFFOLK ) sS.:
, in the year 20~, before me personally
, to me known, who being by
Supervisor of
, the organization described
in and which executed the above instrument; and that he/she has the authority to sign on behalf of
said organization; and that he/she executed the foregoing agreement for and in behalf of said
organization.
August
On this II day of
appeared Scott A. Russell
me duly sworn, did depose and say that he/Stie is the
the Town of Southold
!IJ./f"/~' ~ f7 ~dJ}"A-)
otary Public
LINDA J COOPER
NOTARY PUBLIC, State of New York
NO. Ot C04822563., Suffolk CouQJ.y_
Term Exp!res December 31, 20~
APPROVED:
ATTORNEY GENERAL'S SIGNATURE:
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
Title:
Date:
SIGNATURE PAGE
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below
their signatures.
CONTRACT #M051096
CONTRACTOR
STATE AGENCY
Town of Southold
By:
.-J~a-/~
Scott A. Russell
New York State Department of State
By:
(Print Name)
Date:
8 j7,~
I
Title:
Date:
State Agencv Certification
"In addition to the acceptance of this Contract, I also certify
that original copies of this signature page will be attached
to all other exact copies of this Contract."
Title:
. (Print Name)
SUperV1SOr
STATE OF NEW YORK)
COUNTY OFSUFFOLK ) ss.:
On this J 7 day of August , in the year 20~, before me personally
appeared Scott A. Russell ,tomeknown,whobeingby
me duly sworn, did depose and say that he/ilb>l is the Supervi Bor of
the Town of Southold , the organization described
in and which executed the above instrument; and that he/she has the authority to sign on behalf of
said organization; and that he/she executed the foregoing agreement for and in behalf of said
organization.
k}/}'d"-iJ (J~~
Notary Public
LINDA J COOPER
NOTARY PUBLIC. State of New York
NO. 01 C04822563, Suffolk COYJ)tl'
Term Expires December 3 1 2c(/-k
APPROVED:
ATTORNEY GENERAL'S SIGNATURE:
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Title:
Date:
Date:
SIGNATURE PAGE
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the dates below
their signatures.
CONTRACT #M051096
CONTRACTOR
By:
A~
Scott A. Russell
STATE AGENCY
New York State Department of State
By:
Town of Southold
(Print Name)
Supervisor
(Print Name)
Title:
Date:
Title:
Date:
~)~~~
State Agencv Certification
"In addition to the acceptance ofthis Contract, I also certifY
that original copies of this signature page will be attached
to all other exact copies of this Contract."
STATE OF NEW YORK)
COUNTY OF SUFFOLI<;) sS.:
On this 17 day of Augus t , in the year 20~, before me personally
appeared Scott A. Russell , to me known, who being by
me duly sworn, did depose and say that he/sM is the Supervisor of
the Town of Southold , the organization described
in and which executed the above instrument; and that he/she has the authority to sign on behalf of
said organization; and that he/she executed the foregoing agreement for and in behalf of said
organization.
i~ "', -Ev ~V7~V
Not ry Public
LINDA J COOPER
NOTARY PUBLIC, State of New York
NO. 01 C04822563, Suftolk Coul])y,
Term Expires December 31, 20~
APPROVED:
ATTORNEY GENERAL'S SIGNATURE:
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
Title:
Date:
I
STATE OF NEW YORK
AGREEMENT
This AGREEMENT is hereby made by and between the State of New York
agency (STATE) and the public or private agency (CONTRACTOR) identified on the
face page hereof.
WITNESSETH:
WHEREAS, the STATE has the authority to regulate and provide funding forthe
establishment and operation of program services and desires to contract with skilled
parties possessing the necessary resources to provide such services; and
WHEREAS, the CONTRACTOR is ready, willing and able to provide such
program services and possesses or can make available all necessary qualified
personnel, licenses, facilities and expertise to perform or have performed the services
required pursuant to the terms of this AGREEMENT;
NOW, THEREFORE, in consideration of the promises, responsibilities and
covenants herein, the STATE and the CONTRACTOR agree as follows:
1. Conditions of Agreement
A. This AGREEMENT may consist of successive periods (PERIOD), as
specified within the AGREEMENT or within a subsequent Modification
Agreement(s) (Appendix X). Each additional or superseding PERIOD shall
be on the forms specified by the particular State agency, and shall be
incorporated into this AGREEMENT.
B. Funding for the first PERIOD shall not exceed the funding amount specified
on the face page hereof. Funding for each subsequent PERIOD, if any, shall
not exceed the amount specified in the appropriate appendix for that
PERIOD.
C. This AGREEMENT incorporates the face pages attached and all of the
marked appendices identified on the face page hereof.
2
D. For each succeeding PERIOD of this AGREEMENT, the parties shall prepare
new appendices, to the extent that any require modification, and a
Modification Agreement (the attached Appendix X is the blank form to be
used). Any terms of this AGREEMENT not modified shall remain in effect
for each PERIOD of the AGREEMENT.
To modify the AGREEMENT within an existing PERIOD, the parties shall
revise or complete the appropriate appendix formes). Any change in the
amount of consideration to be paid, or change in the term, is subject to the
approval of the Office of the State comptroller. Any other modifications
shall be processed in accordance with agency guidelines as stated in
Appendix AI.
E. The CONTRACTOR shall perform all services to the satisfaction of the
STATE. The CONTRACTOR shall provide services and meet the program
objectives summarized in the Program Workplan (Appendix D) in accordance
with: provisions of the AGREEMENT; relevant laws, rules and regulations,
administrative and fiscal guidelines; and where applicable, operating
certificates for facilities or licenses for an activity or program.
F. If the CONTRACTOR enters into subcontracts for the performance of work
pursuant to this AGREEMENT, the CONTRACTOR shall take full
responsibility for the acts and omissions of its subcontractors. Nothing in the
subcontract shall impair the rights ofthe STATE under this AGREEMENT.
No contractual relationship shall be deemed to exist between the
subcontractor and the STATE.
G. Appendix A (Standard Clauses as required by the Attorney General for all
State contracts) takes precedence over all other parts ofthe AGREEMENT.
II. Payment and Reporting
A. The CONTRACTOR, to be eligible for payment, shall submit to the ST ATE's
designated payment office (identified in Appendix C) any appropriate
documentation as required by the Payment and Reporting Schedule
(Appendix C) and by agency fiscal guidelines, in a manner acceptable to the
STATE.
3
B. The STATE shall make payments and any reconciliations in accordance with
the Payment and Reporting Schedule (Appendix C). The STATE shall pay
the CONTRACTOR, in consideration of contract services for a given
PERIOD, a sum not to exceed the amount noted on the face page hereof or
in the respective Appendix designating the payment amount for that given
PERIOD. This sum shall not duplicate reimbursement from other sources for
CONTRACTOR costs and services provided pursuant to this AGREEMENT.
C. The CONTRACTOR shall meet the audit requirements specified by the
STATE.
III. Terminations
A. This AGREEMENT may be terminated at any time upon mutual written
consent ofthe STATE and the CONTRACTOR.
B. The STATE may terminate the AGREEMENT immediately, upon written
notice oftermination to the CONTRACTOR, ifthe CONTRACTOR fails to
comply with the terms and conditions of this AGREEMENT and/or with any
laws, rules, regulations, policies or procedures affecting this AGREEMENT.
C. The STATE may also terminate this AGREEMENT for any reason in
accordance with provisions set forth in Appendix A I.
D. Written notice of termination, where required, shall be sent by personal
messenger service or by certified mail, return receipt requested. The
termination shall be effective in accordance with the terms of the notice.
E. Upon receipt of notice of termination, the CONTRACTOR agrees to cancel,
prior to the effective date of any prospective termination, as many
outstanding obligations as possible, and agrees not to incur any new
obligations after receipt of the notice without approval by the STATE.
F. The STATE shall be responsible for payment on claims pursuant to services
provided and costs incurred pursuant to terms of the AGREEMENT. In no
event shall the STATE be liable for expenses and obligations arising from the
program(s) in this AGREEMENT after the termination date.
4
IV. Indemnification
A. The CONTRACTOR shall be solely responsible and answerable in damages
for any and all accidents and/or injuries to persons (including death) or
property arising out of or related to the services to be rendered by the
CONTRACTOR or its subcontractors pursuant to this AGREEMENT. The
CONTRACTOR shall indemnify and hold harmless the STATE and its
officers and employees from claims, suits, actions, damages and costs of
every nature arising out of the provision of services pursuant to this
AGREEMENT.
B. The CONTRACTOR is an independent contractor and may neither hold itself
out nor claim to be an officer, employee or subdivision of the STATE nor
make any claim, demand or application to or for any right based upon any
different status.
V. Property
Any equipment, furniture, supplies or other property purchased pursuant to this
AGREEMENT is deemed to be the property of the STATE except as may
otherwise be governed by Federal or State laws, rules or regulations, or as stated
in Appendix A I.
VI. Safeguards for Services and Confidentiality
A. Services performed pursuant to this AGREEMENT are secular in nature and
shall be performed in a manner that does not discriminate on the basis of
religious belief, or promote or discourage adherence to religion in general or
particular religious beliefs.
B. Funds provided pursuant to this AGREEMENT shall not be used for any
partisan political activity, or for activities that may influence legislation or
the election or defeat of any candidate for public office.
C. Information relating to individuals who may receive services pursuant to this
AGREEMENT shall be maintained and used only for the purposes intended
under the Contract and in conformity with applicable provisions oflaws and
regulations, or specified in Appendix AI.
A-I
APPENDIX A
Standard Clauses for All New York State Contracts
The parties to the attached contract, license, lease, amendment or other
agreement of any kind (hereinafter, "the contract" or "this contract") agree
to be bound by the following clauses which are hereby made a part of the
contract (the word "Contractor" herein refers to any party other than the
State, whether a contractor, licenser, licensee, lessor, lessee or any other
party):
I. EXECUTORY CLAUSE. In accordance with Section 41 ofthe State
Finance Law, the State shall have no liability under this contract to the
Contractor or to anyone else beyond funds appropriated and available for
this contract.
2. NON-ASSIGNMENT CLAUSE. In accordance with Section 138 of
the State Finance Law, this contract may not be assigned by the Contractor
or its right, title or interest therein assigned, transferred conveyed, sublet or
otherwise disposed of without the previous consent, in writing, of the State
and any attempts to assign the contract without the Stale's written consent
are null and void The Contractor may, however, assign its right to receive
payment without the State's prior written consent unless this contract
concerns Certificates of Participation pursuant to Article 5-A of the State
Finance Law.
3. COMPTROLLER'S APPROVAL In accordance with Section 112 of
the State Finance Law (or, if this contract is with the State University or
City University of New York, Section 355 or Section 6218 of the Education
Law), if this contract exceeds $15,000 (or the minimum thresholds agreed
to by the Office of the State Comptroller for certain S.U.N.Y. and C.U.N.Y.
contracts), or if this is an amendment for any amount to a contract which,
as so amended, exceeds said statutory amount, or if, by this contract, the
State agrees to give something other than money when the value or
reasonably estimated value of such consideration exceeds $] 0,000, it shall
not be valid, effective or binding upon the State until it has been approved
by the State Comptroller and filed in his office. Comptroller's approval of
contracts leI by the Office of General Services is required when such
contracts exceed $30,000 (State Finance Law Section 163.6a).
4. WORKERS' COMPENSATION BENEFITS. In accordance with
Section 142 of the State Finance Law, this contract shall be void and of no
force and effect unless the Contractor shall provide and maintain coverage
during the life of this contract for the benefit of such employees as are
required to be covered by the provisions of the Workers' Compensation
Law.
5. NON-DISCRIMINATION REOUIREMENTS. To the extend
required by Article 15 of the Executive Law (also known as the Human
Rights Law) and all other State and Federal statutory and constitutional
non-discrimination provisions, the Contractor will not discriminate against
any employee or applicant for employment because of race, creed, color,
sex, national origin, sexual orientation, age, disability or marital status.
Furthermore, in accordance with Section 220-e of the Labor Law, if this is
a contract for the construction, alteration or repair of any public building or
public work or for the manufacture, sale or distribution of materials,
equipment or supplies, and to the extent that this contract shall be
performed within the State of New York, Contractor agrees that neither it
nor its subcontractors shall, by reason ofrace, creed, color, disability, sex,
or national origin: (a) discriminate in hiring against any New York State
citizen who is qualified and available to petfonn the work; or (b)
discriminate against or intimidate any employee hired for the perfonnance
of work under this contract. If this is a building service contract as defined
in Section 230 of the Labor Law, then, in accordance with Section 239
May 2003
thereof, Contractor agrees that neither it nor its subcontractors shall by
reason of race, creed, color, national origin, age, sex, or disability: (a)
discriminate in hiring against any New York State citizen who is qualified
and available to perfonn the work; or (b) discriminate against or intimidate
any employee hired for the performance of work under this contract.
Contractor is subject to fines of$50.00 per person per day for any violation
of Section 220-e or Section 239 as well as possible tennination of this
contract and forfeiture of all moneys due hereunder for a. second or
subsequent violation.
6. WAGE AND HOURS PROVISIONS. Ifthis is a public work contract
covered by Article 8 of the Labor Law or a building service contract
covered by Article 9 thereof, ne,ither Contractor's employees nor the
employees of its subcontractors may be required or pennitted to work more
than the number of hours or days stated in said statutes, except as otherwise
provided in the Labor law and as set forth in prevailing wage and
supplement schedules issued by the State Labor Department. Furthermore,
Contractor and its subcontractors must pay at least the prevailing wage rate
and payor provide the prevailing supplements, including the premium rates
for overtime pay, as detennined by the State Labor Department in
accordance with the Labor Law.
7. NON-COLLUSIVE BIDDING REOUlREMENT. In accordancewith
Section 139-d of the State Finance Law, if this contract was awarded based
upon the submission of bids, Contractor warrants, under penalty of perjury,
that its bid was arrived at independently and without collusion aimed at
restricting competition. Contractor further warrants that, at the. time
Contractor submitted its bid, an authorized and responsible person executed
and delivered to the State a non-collusive bidding certification on
Contractor's behalf.
8. INTERNATIONAL BOYCOTT PROHIBITION. In accordance with
Section 220-f of the Labor Law and Section 139-h of the State Finance
Law, if this contract exceeds $5,000, the Contractor agrees, as a material
condition of the contract, that neither the Contractor nor any substantially
owned or affiliated person, finn, partnership or corporation has participated,
is participating, or shall participate in an international boycott in violation
of the federal Ex.port Administration Act of 1979 (50 USC App. Sections
2401 et seq.) or regulations thereunder. If such Contractor, or any of the
aforesaid affiliates of Contractor, is convicted or is otherwise found to have
violated said laws or regulations upon the final determination of the United
States Commerce Department or any other appropriate agency of the United
States subsequent to the contractors execution, such contract, amendment
or modification thereto shall be rendered forfeit and void. The Contractor
shall so notify the State Comptroller within five (5) business days ofsuch
conviction, detennination or disposition of appeal (2NYCRR 105.4).
9. SET-OFF RIGHTS. The State shall have all of its common law,
equitable and statutory rights of set-off. These rights shall include, but not
be limited to, the State's option to withhold for the purposes of set-off any
moneys due to the Contractor under this contract up to any amounts due and
owing to the State with regard to this contract, any other contract with any
State department or agency, including any contract for a term commencing
prior to the term of this contract, plus any amounts due and owing to the
State for any other reason including, without limitation, tax delinquencies,
fee delinquencies or monetary penalties relative thereto,
A-2
The State shall exercise its set~offrights in accordance with nonnal State
practices including, in cases of set-off pursuant to an audit, the finalization
of such audit by the State agency, its representatives, or the State
Comptroller,
10. RECORDS. The Contractor shall establish and maintain complete and
accurate books, records, documents, accounts and other evidence directly
pertinent to performance under this contract (hereinafter, collectively. "the
Records"). The Records must be kept for the balance of the calendar year
in which they were made and for six (6) additional years thereafter. The
State Comptroller, the Attorney General and any other person or entity
authorized to conduct an examination, as well as the agency or agencies
involved in this contract, shall have access to the Records during normal
business hours at an office of the Contractor within the State of New York
or, if no such office is available, at a mutually agreeable and reasonable
venue within the State, for the term specified above for the purposes of
inspection, auditing and copying. The State shall take reasonable steps to
protect from public disclosure any of the Records which are exempt from
disclosure under Section 87 of the Public Officers Law (the "Statute")
provided that: (I) the Contractor shall timely inform an appropriate State
official, in writing, that said records should not be disclosed; and (ii) said
records shall be sufficiently identified; and (iii) designation of said records
as exempt under the Statute is reasonable. Nothing contained herein shall
diminish, or in any way adversely affect, the State's right to discovery in any
pending or future litigation.
11. IDENTIFYING INFORMATION AND PRIVACY NOTIFICA-
TION. (a) FEDERAL EMPLOYER IDENTlFICA TlON NUMBER and/or
FEDERAL SOCIAL SECURJTY NUMBER All invoices or New York
State standard vouchers submitted for payment for the sale of goods or
services or the lease of real or personal property to a New York State
agency must include the payee's identification number, i.e., the seller's or
lessor's identification number. The number is either the payee's Federal
employer identification number or Federal social security number, or both
such numbers when the payee has both such numbers. Failure to include
this number or numbers may delay payment. Where the payee does not have
such number or numbers, the payee, on its invoice or New York State
standard voucher, must give the reason or reasons why the payee does not
have such number or numbers.
(b) PRJV ACY NOTIFICATION. (I) The authority to request the above
personal information from a seller of goods or services or a lessor of real or
personal property, and the authority to maintain such infonnation, is found
in Section 5 of the State Tax Law. Disclosure of this information by the
seller or lessor to the State is mandatory. The principal purpose for which
the information is collected is to enable the State to identify individuals,
businesses and others who have been delinquent in filing tax returns or may
have understated their tax liabilities and to generally identify persons
affected by the taxes administered by the Commissioner of Taxation and
Finance. The information will be used for tax administration purposes and
for any other purpose authorized by law.
(2) The personal information is requested by the purchasing unit of the
agency contracting to purchase the goods or services or lease the real or
personal property covered by this contract or lease. The information is
maintained in New York State's Central Accounting System by the Director
of Accounting Operations, Office of the State Comptroller, AESOB,
Albany. New York 12236.
12. EQVALEMPLOYMENTOPPORTUNITIES FOR MINORITIES
AND WOMEN. In accordance with Section 312 oflhe Executive Law, if
this contract is: (I) a written agreement or purchase order instrument,
providing for a total expenditure in excess of $25,000.00, whereby a
contracting agency is committed to expend or does expend funds in return
for labor, services, supplies, equipment, materials or any combination of the
foregoing, to be perfonned for, or rendered or furnished to the contracting
May 2003
agency; or (ii) a written agreement in excess of $1 00,000,00 whereby a
contracting agency is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or
renovation of real property and improvements thereon; or (iii) a written
agreement in excess of$IOO,OOO.OO whereby the owner of. State assisted
housing project is committed to expend or does expend funds for the
acquisition, construction, demolition, replacement, major repair or ren-
ovation of real property and improvements thereon for such project, then:
(a) The Contractor will not discriminate against employees or applicants for
employment because of race, creed, color, national origin, sex, age,
disability ormarital status, and will undertake or continueexistingprograrns
of affirmative action to ensure that minority group members and women are
afforded equal employment opportunities without discrim-ination.
Affirmative action shall mean recruitment, employment, job assignment,
promotion, upgradings, demotion, transfer, layoff, or termination and rates
of payor other forms of compensation;
(b) at the request of the contracting agency, the Contractor shall request
each employment agency, labor union, or authorized representative of
workers with which it has a collective bargaining or other agreement or
understanding, to furnish a written statement that such employment agency,
labor union or representative will not discriminate on the basis of race,
creed, tolor, national origin, sex, age, disability or marital status and that
such union or representative will affirmatively cooperate in the
implementation of the contractor's obligations herein; and
c) the Contractor shall state, in all solicitations or advertisements for
employees, that, in the perforrnance of the State contract, all qualified
applicants will be afforded equal employment opportunities without dis-
crimination because of race, creed, color, national origin, sex, age, disability
or marital status.
Contractor will include the provisions of "a, "b", and "c" above, in every
subcontract over $25,000.00 for the construction, demolition, replacement,
major repair, renovation, planning or design of real property and
improvements thereon (the "Work") except where the Work is for the
beneficial. use of the Contractor. Section 312 does not apply to: (I) work,
goods or services unrelated to this contract; or (ii) employment outside New
York State; or (iii) banking services, insurance policies or the sale of
securities. The State shall consider compliance by a contractor or
subcontractor with the requirements of any federal law concerning equal
employment opportunity which effectuates the purpose of this section. The
contracting agency shall determine whether the imposition of the
requirements of the provisions hereof duplicate or conflict with any such
federal law and if such duplication or conflict exists, the contracting agency
shall waive the applicability of Sect ion 312 to the extent of such duplication
or conflict. Contractor will comply with all duly promulgated and lawful
rules and regulations of the Governor's Office of Minority and Women's
Business Development pertaining hereto.
13. CONFLICTING TERMS. In the event of a conflict between the
terms of the contract (including any and all attachments thereto and
amendments thereof) and the terms of this Appendix A, the tems of this
Appendix A shall control.
14. GOVERNING LA W, This contract shall be governed by the laws of
the State of New York except where the Federal supremacy clause requires
otherwise.
A-3
15. LATE PAYMENT. Timeliness of payment and any interest to be paid
to Contractor for late payment shall be governed by Article Il-A of the
State Finance Law to the extent required by law.
16. NO ARBITRATION. Disputes involving this contract, including the
breach or alleged breach thereof, may not be submitted to binding
arbitration (except where statutorily authorized), but must, instead, be heard
in a court of competent jurisdiction of the State of New York.
17. SERVICE OF PROCESS. In addition to the methods of service
allowed by the State Civil Practice Law & Rules ("CPLR"), Contractor
hereby consents to service of process upon it by registered or certified mail,
return receipt requested. Service hereunder shall be complete upon
Contractor's actual receipt of process or upon the State's receipt of the
return thereof by the United States Postal Service as refused or
undeliverable. Contractor must promptly notify the State, in writing, of each
and every change of address to which service of process can be made.
Service by the State to the last known address shall be sufficient. Contractor
will have thirty (30) calendar days after service hereunder is complete in
which to respond.
18. PROHIBITION ON PURCHASE OF TROPICAL HARD-
WOODS. The Contractor certifies and warrants that all wood products to
be used under this contract award will be in accordance with, but not
limited to, the specifications and provisions of State Finance Law 9165.
(Use of Tropical Hardwoods) which prohibits purchase and use of tropical
hardwoods, unless specifically exempted, by the State or any governmental
agency or political subdivision or public benefit corporation. Qualification
for an exemption under this law will be the responsibility ofthe contractor
to establish to meet with the approval of the State.
In addition, when any portion of this contract involving the use of woods,
whether supply or installation, is to be perfonned by any subcontractor, the
prime Contractor will indicate and certify in the submitted bid proposal that
the subcontractor has been infonned and is in compliance with
specifications and provisions regarding use of tropical hardwoods as
detailed in 9165 State Finance Law. Any such use must meet with the
approval of the State, otherwise, the bid may not be considered responsive.
Under bidder certifications, proof of qualification for exemption will be the
responsibility of the Contractor to meet with the approval of the State.
19. MACBRIDE FAIR EMPLOYMENT PRINC[PLES.ln accordance
with the MacBride Fair Employment Principles (Chapter 807 of the Laws
of 1992), the Contractor hereby stipulates that the Contractor either (a) has
no business operations in Northern Ireland, or (b) shall take lawful steps in
good faith to conduct any business operations in Northern Ireland in
accordance with the MacBride Fair Employment Principles (as described
in Section 165 of the New York State Finance Law), and shall permit
independent monitoring of compliance with such principles.
20. OMNIBUS PROCUREMENT ACT OF [992 It is the policy of New
York State to maximize opportunities for the participation of New York
State business enterprises, including minority and women.o\VTled business
enterprises as bidders, subcontractors and suppliers on its procurement
contracts,
Infonnation on the availability of New York Stale subcontractors and
suppliers is available from:
NYS Department of Economic Development
Division for Small Business
30 South Pearl Street, 7th floor
Albany, New York 12245
518-292-5220
May 2003
A directory of certified minority and women.owned business enterprises
is available from:
NYS Department of Economic Development
Minority and Women's Business Development Division
30 South Pearl Street, 2nd floor
Albany, New York 12245
http://www.empire.state.ny.us
The Omnibus Procurement Act of 1992 requires that by signing this bid
proposal or contract, as applicable, Contractors certify that whenever the
total bid amount is greater than $] million:
(a) The Contractor has made reasonable efforts to encourage the
participation of New Yark State Business Enterprises as suppliers and
subcontractors, including certified minority and women-owned business
enterprises, on this project, and has retained the documentation of these
efforts to be provided upon request to the State;
(b) The Contractor has complied with the Federal Equal Opportunity Act
of 1972 (P.L. 92-261), as amended;
(9) The Contractor agrees to make reasonable efforts to provide
notification to New York State residents of employment opportunities on
this project through listing any such positions with the Job Service
Division of the New Yark State Department of Labor, or providing such
notification in such manner as is consistent with existing collective
bargaining contracts or agreements. The Contractor agrees to document
these efforts and to provide said documentation to the State upon request;
and
(d) The Contractor acknowledges notice that the State may seek to obtain
offset credits from foreign countries as a result of this contract and agrees
to cooperate with the State in these efforts.
21. RECIPROCITY AND SANCTIONS PROVISIONS. Bidders are
hereby notified that if their principal place of business is located in a
country, nation, province, state or political subdivision that penalizes New
York State vendors, and if the goods or services they offer will be
substantially produced or performed outside New York State, the Omnibus
Procurement Act 1994 amendments and 2000 amendments (Chapter 684
and Chapter 383 respectively) require that they be denied contracts which
they would otherwise obtain. NOTE: As of May 15, 2002, the list of
discriminatory jurisdictions subject to this provision includes the states of
South Carolina, Alaska, West Virginia, Wyoming, Louisiana and Hawaii.
Contact NYS Department of Economic Development for a current list of
jurisdictions subject to this provision.
22. PURCHASES OF APPAREL. In accordance with State Finance
Law 162 (4-a), the State shall not purchase any apparel from any vendor
unable or unwilling to certify that: (I) such apparel was manufactured in
compliance with all applicable labor and occupational safety laws,
including, but not limited to, child labor laws, wage and hours laws and
workplace safety laws, and (ii) vendor will supply, with its bid (or, if not
a bid situation, prior to or at the time of signing a contract wilh the State),
ifkno\','O, the names and addresses of each subcontractor and a list of all
manufacturing plants to be utilized by the bidder.
AI-I
APPENDIX At
Agency-Specific Clauses
l. General
A. For the purposes ofthis Agreement, the terms "State" and "Department" are
inter-changeable, unless the context requires otherwise.
B. The Contract Period as set forth on the Face Page is the inclusive period
within which the provisions of this Agreement shall be performed. Costs
incurred for project activities conducted prior to or after the Contract Period
will not be reimbursed under this Agreement.
C. The Contractor and Project (as described in the Legislative Initiative Form
provided to the Contractor by the Department and incorporated herein by
references and as detailed in the Program Workplan, Appendix D) have been
identified to the Department for receipt of a local grant award not to exceed
the Funding Amount as set forth on the Contract Face Page.
D. The Department shall not be liable for expenses of any kind incurred in
excess of the Funding Amount, and shall not be responsible for seeking
additional appropriations or other sources of funds for the Project.
E. The Contractor shall perform all services to the satisfaction of the
Department. The Contractor shall provide all services and meet the program
objectives set forth in Appendix D in accordance with: provisions of this
Agreement; relevant laws, rules and regulations, administrative and fiscal
guidelines; and where applicable, operating certificates for facilities or
licenses for an activity or program.
F. Pursuant to the provisions set forth in Section V., page 3 of this Agreement,
the ownership of all property described therein shall reside with the
Contractor unless otherwise specified in writing by the Department at
anytime during the term of this Agreement and up to thirty (30) days
following the issuance of the final payment.
Al-2
II. Funding
A. Funding for this project has been appropriated in the Community Projects
Fund as established by Section 99-d ofthe State Finance Law (Chapter 474
ofthe Laws of 1996). Pursuant to Paragraph 6(a) of Section 99-d, "The state
shall not be liable for payments pursuant to any contract, grant or agreement
made pursuant to an appropriation in any account of this fund if insufficient
monies are available for transfer to such account of this fund, after required
transfers pursuant to subdivision three of this section."
B. Notwithstanding the Contract Period set forth on the Face Page, absent
reappropriation in the subsequent State budget, funds for this project will
cease to be available for payments on September 15,2007; in that event, to
afford reasonable assurance that payment can be made by the Department,
final payment requests must be received by the Department's payment office
by not later than August 20,2007.
III. Terminations
A. In addition to any other actions authorized by this Agreement, the
Department may terminate the Agreement in the best interests ofthe State of
New York by providing written notice to the Contractor as provided in this
Agreement.
B. The Contractor shall complete the project as set forth in this Agreement, and
failure to render satisfactory progress or to complete the project to the
satisfaction of the State may be deemed an abandonment of the project and
may cause the suspension or termination of any obligation of the State. In the
event the Contractor should be deemed to have abandoned the project fo any
reason or cause other than a national emergency or an Act of God, all monies
paid to the Contractor by the State and not expended in accordance with this
Agreement shall be repaid to the State upon demand. If such monies are not
repaid within one year after such demand, the State Comptroller of the State
of New York may cause to be withheld from any State assistance to which the
Contractor would otherwise be entitled an amount equal to the monies
demanded.
AI-3
C. In the event that the Department has provided written notice to the Contractor
directing that the Contractor correct any failure to comply with this
Agreement, the Department reserves the right to direct that the Contractor
suspend all work during a period oftime to be determined by the Department.
Ifthe Contractor does not correct such failures during the period provided for
in the notice, this Agreement shall be deemed to be terminated after
expiration of such time period. During any such suspension, the Contractor
agrees not to incur any new obligations after receipt of the notice without
approval by the Department.
IV. Vendor (Contractor) Responsibility
A. The Department is required to conduct a review of a prospective contractor
to provide reasonable assurance that the contractor is responsible. To be
considered responsible a contractor should have appropriate legal authority
to do business in New York State, a satisfactory record of integrity,
appropriate financial, organizational and operational capacity and controls
and acceptable performance on previous governmental contracts, if any. The
State and any of it's agencies may use information gathered from whatever
resources it deems appropriate to assist in making a responsibility
determination.
B. If the prospective contractor is a non-governmental entity and this contract
has a total value in excess of $15,000 in state-provided funds a Vendor
Responsibility Questionnaire, with certification is included with the contract
package. This Questionnaire is designed to provide information to assist the
contracting agency in assessing a contractor's responsibility prior to entering
into a contract and must be completed and returned with the contract.
C. Contractor hereby acknowledges that, where required, the Vendor
Responsibility Questionnaire and certification is made a part ofthis contract
by reference hereto and that any misrepresentation of fact in the
Questionnaire and attachments, or in any contractor responsibility
information that may be requested by the Department, may result in
termination ofthis contract. During the term of this Contract, any changes in
the information provided in the Questionnaire shall be disclosed to the
Department, in writing, in a timely manner. Failure to make such disclosure
may result in a determination of non-responsibility and termination of the
contract.
AI-4
D. Should it be determined at any time that a contractor is not responsible,
the Department will notify the contractor in writing setting forth the basis
for the determination and affording the contractor reasonable time in
which to refute the determination, justify why the basis for the
determination is not relevant to this contract or to take corrective action
to eliminate the responsibility impediment. Ifthe responsibility condition
cannot be reconciled to the satisfaction of the Department and the State
the contract, or contract offer will be terminated by written notification.
v. Fully-Executed Agreement or Amendment Thereto
A. If this Agreement, or amendments thereto, allocates funds totaling $15,000
or less, it shall be deemed to be fully executed when approved and signed by
the Contractor and the Department.
B. Ifthis Agreement, or amendments thereto, allocates funds totaling more than
$15,000, it shall be deemed to be fully executed when approved by the Office
of the State Comptroller.
Attachment 1 to Appendix Al
Article 15-A of the New York State Executive Law
The Department of State administers a Minority and Women-owned Business
Enterprises (MWBE) Program as mandated by Article 15-A of the New York State
Executive Law. This law supersedes any other provision in state law authorizing or
requiring an equal employment opportunity program or a program for securing
participation by minority and women-owned business enterprises. Under this law, all
state agencies must, subject to certain exceptions, establish goals for minority and
women-owned business participation in certain state contracts and grants. Where
MWBE goals are required, even in circumstances where this goal is zero, a Quarterly
Grantee Report is required to be submitted to the Affirmative Action Office of the
Department on forms provided by the Department.
Article l5-A requires that rules and regulations be established for contracts
entered into by the Department. In accordance with Article l5-A, goals must be set
for contracts entered into by the Department in excess of$25,000 for labor, services,
supplies, equipment, and materials, or any combination of the foregoing, and for
contracts entered into by the Department in excess of $100,000 for acquisition,
construction, demolition, replacement, major repair, renovation or improvement of
real property. In applying these rules and regulations, the Department must consider
the availability of certified minority and women-owned businesses in the region in
which the state contract will be performed, the total dollar value of the Contract, the
scope of work to be performed, and the project size and term.
The contractor will, when required as a part of the bid or proposal, submit a
Staffing Plan on the form provided by the Department. This Plan will detail the work
force anticipated in the performance of the state contract broken down by ethnic
background, gender, and Federal Occupational Categories.
After a bid opening and prior to the award of a state contract, the contractor will
submit an Equal Employment Opportunity (EEO) Policy Statement to the Department
within the time frame established by the Department. The law requires that, as a
precondition to entering into a valid and binding state contract, the contractor shall
agree to the following stipulations and will include them in the EEO Policy
Statement:
. The contractor will not discriminate against any employee or applicant
for employment because of race, creed, color, national origin, sex, age,
disability or marital status.
. The contractor will undertake or continue eXlstmg programs of
affirmative action to ensure that minority group members and women are
afforded equal employment opportunities without discrimination because
of race, creed, color, national origin, sex, age, disability or marital status.
For these purposes, affirmative action applies in areas of recruitment,
employment, job assignment, promotion, upgrading, demotion, transfer,
layoff, or termination and rates of payor other forms of compensation.
. The contractor will make active and conscientious efforts to employ and
to utilize minority group members and women at all levels and in all
segments of its work force on state contracts, and the contractor will
document these efforts.
. The contractor will state in all solicitations and advertisements for
employees that, in the performance of the state contract, all qualified
applicants will be afforded equal employment opportunities without
discrimination because of race, creed, color, national origin, sex, age,
disability or marital status.
. The contractor will, at the request of the Department, request each
employment agency, labor union, or authorized representative of workers
at which it has a collective bargaining or other agreement or understanding,
to furnish a written statement that such employment agency, labor union,
or representative will not discriminate because of race, creed, color,
national origin, sex, age, disability or marital status, and that such union or
representative will affirmatively cooperate in the implementation of the
contractor's obligations herein.
. The contractor will include the provisions regarding the EEO Policy
Statement and the Staffing Plan enumerated above in each and every
subcontract of a state contract in such a manner that the subcontractor is
bound by these requirements.
. Failure to provide an EEO Policy Statement and a Staffing Plan without
reasonable written justification or commitment to provide these
requirements by a specified date will result in rejection of the contractor's
bid or proposal.
. After the award of a state contract, the contractor will submit to the
Department a Work Force Employment Utilization Report, on the fonn
supplied by the Department, detailing the work force actually utilized on
the state contract, by ethnic background, gender and Federal Occupational
Categories, as specified on the fonn. This Report will be submitted to the
Department on a quarterly basis throughout the life of the contract.
. The contractor, and any of its subcontractors, may be required to submit
compliance reports relating to their operations and implementation of their
affinnative action or equal employment opportunity program in effect as of
the date the state contract is executed.
Questions regarding this program should be directed to the New York State
Department of State's Affinnative Action Office, 41 State Street, Albany, New York
12231, 518-474-2752. To assist potential contractors, a copy of the NYS Directory
of Certified Minority and Women-owned Business Enterprises is made available for
inspection at the Department's Affirmative Action Office. The Department makes
no representation with respect to the availability or capability of any business listed
in the Directory.
8-1
APPENDIX B
Budget
Budget Summary Sheet
A. SALARIES, WAGES AND FRINGE $
B. TRAVEL $
C. SUPPLIES/MATERIALS $
D. EQUIPMENT $
E. CONTRACTUAL SERVICES $18,700
F. OTHER $
TOTAL $ 18,700*
Note: $1,200 to be paid by the Town of Southold
The TOTAL of your BUDGET must equal the amount of your allocation as shown
on the CONTRACT FACE PAGE!
The BUDGET is intended to show the items of expense which will be funded under
this Contract. Please do not show the entire cost of the project if it exceeds the
amount of funding provided by this Contract.
Questions regarding Budget preparation? Call 518-486-3905
B-2
Budget Detail Sheet
A. SALARIES. WAGES AND FRINGE
Amount Charged
Title to this Proiect
TOTAL SALARIES, WAGES AND FRINGE $
B. TRAVEL
Please indicate destination, purpose and cost of such travel.
TOTAL TRAVEL
$
Budget Detail Sheet
B-3
C. SUPPLIES/MATERIALS
Please use general categories such as office supplies, printing supplies, small tools, building
materials and like category descriptions. Indicate the cost of each category.
TOTAL SUPPLIES/MA TERIALS
$
D. EQUIPMENT
Please list each item of equipment that exceeds $200.00 per item and has a useful life
of one year or more. Group items of less than $200.00 each into general categories
indicating total cost per category.
TOTAL EQUIPMENT
$
Budget Detail Sheet
8-4
E. CONTRACTUAL SERVICES
This category includes items such as telephone, postage, rent, utilities, rental or repairs to
equipment, lease of equipment, contracted services and contracted construction costs.
SEE ATTACHED PRICE QUOTE AND MATERIAL LIST
TOTAL CONTRACTUAL SERVICES
$
Iff ?61J
F. OTHER
Please specify what these costs are.
TOTAL OTHER
$
LESLIE - JOHNSON CORP.
August 23, 2006
Town of South old
P.O. Box 1179
Southold, NY 11971
Attn: James Richtor
Re: School Speed Limit Signs
Front Stteet
Gentlemen,
As per your request:, the following is our revised quotation to supply and install of one (1) School
Speed Limit Sign Unit.
1. Supply and install one (1) Speed Limit beacon, one (1) aluminum pole,
one (1) flashing signal, one (1) speed limit sign, one (1) concrete base,
one (1) cabinet and one (1) time clock.
For The Lump Sum Of:
$9,350.00 each unit
We believe that two (2) units are required, 300 feet from each approach to the school as per NYS
law.
*This quote is valid for 30 days.
We thank you for the opportunity to quote this project. If you would like to proceed please issue a
purchase order in the amount referenced above. We look forward to a favorable response. If you
require any further information, please contact the undersigned at this office.
Very truly yours, /'-"
~rrfJo. hn:o~.;~J;; I ./i $J..
! !/V'/i '.' ..~
'-/ (! [J;tt/ . - .// )
obiJpataiJ/ t:/ /
Vice President
RP:lsI
Enclosure - 3 Pages of submittals
CC: Charles Kozora, Superintendent of Schools
263 Calebs Path, Hauppauge, NY 11788 . Tel: 631-234-8383 . Fax: 631-582-6325
The Power of Ingenuity
LESLlE-JOHNSON CORP.
SUBMllTAL FOR RECORD PURPOSES
Project: Front Street School Speed Limtt Signs
Item: 8" Signal Sections used in the Flashing Beacon Assy.
Specification Sheet
2365 Oak Ridge Way.
Vista, CA92081. USA.
Phone 760-727-8100 .
Fax 760-727-8264 .
www.mccaintraffic.com
Vehicle Signals
ALUMINUM 200MM I 8" SECTIONS PAINTED YELLOW
YELLOW SECTIONS WITH YELLOW INCANDESCENT
McCain Traffic Supply's signals are
designed for low maintenance and
increased durability. In addition, the
ability to interchange aluminum and
polycarbonate components.
McCain Traffic Supply reserves the right to change
product specifications without notice. McCain 01/04
...Ye!}J~!~..~Jgn!!J!:t
GENERAL:
". -.,.~"~""",."",=""~""c;,,,,,,,,,,,~'C,,,.,,,,,:;,.,,,_.,,,,,,=,~~,,,,,,=~=,"~7.''',,,-",,_._,,,,.,,,,_,,,,.-,,,.~.,.,,_,.",,,~~",,_'''.,,.,-,,.<.
ALUMINUM:
HOUSING:
DOORAND
MOUNTING:
REFLECTOR:
LAMP
SOCKET:
LENS:
OPTICAL:
REFLECTOR
RING:
TERMINAL
BLOCK:
VISORS:
PAINTING:
WARRANTY:
OUf unique design permits the user to interchange all of the components in the 12 inch aluminum signal head with all of the
components in the 12 inch polycarbonate signal head. Induded in our design is the same capability to interchange 8 inch
aluminum signal heads with 8 inch polycarbonate signal heads.
Die cast from aluminum alloy. Our in house die casting foundry allows us complete control in maintaining the highest quality.
Die cast aluminum or polycarbonate injection molded in one piece. To provide strength and positive locking when using the self
locking fittings, each housing is molded with a 5<> serrated boss and reinforcing ribs top and bottom. Also on top and bottom an
opening to accept standard 11/2 inch pipe hardware. Polycarbonate housings have four additional knockout locations to allow
use of four 10-32 x 11/2" machine screws as an additional means of coupling sections. All housings have a cast boss provided
for mounting a 5 or6 position terminal strip. The words, red, amber, and green are cast next to each boss to identify socket lead
wire attachment. The modular design permits coupling of various 8 and 12 inch signal configurations.
Die cast aluminum or polycarbonate injection molded with two integrated hinge lugs mounted to the housing with two stainless
steel hinge pins. Positive latching is achieved with stainless steel eyebolts and wing nut assemblies. A moisture proof and dust
tight seal is assured with an E.P.D.M. rubber gasket fitted into the gasket channel cast in the perimeter of the door. On
polycarbonate signal doors four metal threaded inserts are molded in for added strength to the visor attachment screws.
Bright specular alzak aluminum. (Standard) Silvered glass in stock. (Optional)
Phenolic body with serrated base to pennit positive locking and adjustable positioning of lamp filament. Socket secured by
reflector bail. For identification, the leads are color coded and have fast on leads to permit installation and removal without the
use of any special tools. Wiring insulation conforms to conductor rating of 10S<>C and is 18 AWG.
Either LED, glass, or polycarbonate as specified. Standard lenses, (red, amber, green) meet the latest ITE requirements.
Lenses fit into specially extruded EPDM gaskets which are placed into the door with four stainless lens clips and stainless
steel screws, to create a moisture and dust proof seal.
The entire design permits a positive contact of the door, lens, silicone reflector, and silicone socket gasket assemblies which
create a moisture and dust tight atmosphere.
Die cast aluminum ring is mounted in the signal housing using stainless steel dowel pins and a spring assembly, permitting
hinging and removal of the reflector assembly without the use of any special tools.
Each signal is provided with a 5 or 6 section 12 terminal barrier strip; one side with a quick disconnect terminal for socket leads.
The opposite with a screw clamp terminal for field wiring.
Formed from aluminum alloy. Visors mount with 4 stainless steel screws to the face of the door. "Twist-on type" full circle,
tunnel, angle, or cap visors available, as specified. Polycarbonate visors are one piece molded and have twist-on atlaching
ears to match aluminum visors.
All exterior surfaces of the housing, door, visors, and back plates are cleaned and "powder coated" or painted to your specifi~
cations. Powder coating is a modern "dry painting" process with an exceptionally high resistance to impact and weather. The
powder is applied electrostatically then melted and fused into a smooth coating, in a baking oven.
Standard colors are: Dark Olive Green FS595A 14056; Fed Yellow FS595A 13538; Dull Black FS595A 37038. Custom colors
are available upon request. Ask for a color chart when ordering.
The McCain Traffic Signal is warranted against defects in materials and workmanship for a period of one (1) year from the date
of original shipment.
Mission Statement
To serve our customers by providing
the best quality of products and
service the industry has to offer.
2365 Oak Ridge Way. Vista, CA 92081, USA. Phone 760-727-8100. Fax 760-727-8264. www.mccaintraffic.com
McCain reserves the right to change product specifications without notice. McCain 01/04
III [eJ e
STOP
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S{~MlIU\
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1-5 AIRPORT (symbol) I IB",18" 24",24"130"xJO"
1-6 BUS STATION (symbol) I 18",IB" 24"'24"130"'30'"
I~____ LIBRARY is~mbol)__ _ _ __l__ _ 18"'~"I1~"14"130"'30"
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REDUCED SPEED AHEAD IB",24"I24"xJo" 36",48" 48",60,,1
SCHOOL BUI STOP AHEAD I 30"'30"136"'36"11
WATCH fOR SCHOOL BUS --- ---- -----124'~1f- 30,~jO" --- --
SCHOOL BUS TURN AROUND 14",24" 30"xJO"11 I
SLOW SCHOOL ZONE J 24",14" 30"xJO"
AM TO PM 14"<10" 36", IS" 48",10"
WHEN CHILDREN ARE PRESENT ~ -'14''',10'' 36",15" 48",10"
SCHOOL 14",B" 36",11" 48",16"
WHEN flASHING 14",10" 36",15" 48",20"
SCHOOL SPEED_- fLASHING 14",48" 36",71" 48",96"
. . END SCHOOlIONE~--18",14" 114"'30" --. -.- J6';;4-8~ 48'\60"
~\,i' SRS-II STOP WHEN SCHOOL BUS STOPS 124",14" I
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STOP - CHILDREN/CROSSWALK 18",24" 24",30" , I
'i, W16-1 FT SUPPLEMENTAL 14",18" 30",14" I I
WI6-2. FT SUPPLEMENTAL 24",12" 30",18"
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C-l
APPENDIX C
Payment and Reporting Schedule
I. This is a cost reimbursement Agreement. The Contractor may claim and be
reimbursed for eligible project costs incurred (costs of eligible project activities
conducted, and goods and services received and accepted by the Contractor)
within the Contract Period. The total of such reimbursement shall not exceed the
Funding Amount for this Agreement and shall be claimed by the Contractor in
accordance with the payment option selected below.
PAYMENT OPTIONS: Circle the option to be applied to this agreement.
Example: Option A
Option A: Payment-In-Full For Completed Project
1. In the event that the project has been completed and all eligible project costs
incurred within the Contract Period and prior to the submission of this
Agreement to the Department for execution, the Contractor may request a
one-time payment-in-full with the submission of the Agreement.
2. Complete the contract documents in accordance with the instructions, making
sure that the contract budget categories add up to the total Funding Amount
regardless ofthe total costs to be claimed. Ifthe total costs to be claimed are
less than the Funding Amount, the claim on the Standard Voucher (AA.
below) will reflect actual expenditures.
3. Complete the Program Workplan (Appendix D) making sure it accurately
describes the project activities completed and the dates of completion. If
the project was on-going in nature, specify the time- frame (start and end
dates) that costs were incurred. Ifthe project was for equipment, supplies or
commodities purchases, specify the delivery date(s) of the item(s)
purchased.
4. Complete the Standard Voucher received with the contract documents in
accordance with the instructions, with the exception of Section 6. Put the
following statement in Section 6:
"Requesting payment-in-full for eligible project costs
incurred pursuant to all terms and conditions of Contract
#(insert contract number) submitted herewith."
C-2
5. Submit the completed contract documents and voucherc1aiming payment-in-
full in accordance with the instructions. Upon full execution of the
Agreement, payment will be made pursuant to the schedule set forth in II.
below, and a copy of the fully-executed Agreement will be sent to you for
your records.
Option B: Periodic Progress Payments
I. Contractor may request periodic progress payments for eligible project costs
incurred following full execution of the Agreement by both parties.
2. Complete the contract documents and submit them to the Department in
accordance with the instructions. Do not submit a voucher or other payment
documents at this time.
3. Upon full execution, a copy of the fully-executed Agreement and payment
request documents and instructions for claiming progress payments will be
sent to you.
4. Reimbursement for eligible project costs incurred will be made upon receipt
and approval of properly completed payment requests submitted in
accordance with III. below.
Option C: Advance and Progress Payment(s)
I. Contractor may request an advance equal to twenty-five percent (25%) of the
Funding Amount.
2. Complete the contract documents in accordance with the instructions.
Complete the Standard Voucher in accordance with the instructions inserting
the statement "25 percent advance" in Section 6. Submit the completed
contract documents and advance voucher to the Department in accordance
with the instructions.
3. Upon full execution of the Agreement, the advance will be issued in
accordance with the schedule set forth in II. below and a copy of the fully-
executed Agreement and payment request documents and instructions for
claiming progress payments will be sent to you.
C-3
4. Upon receipt of a progress payment request submitted in accordance with III.
below, the Department will determine the total eligible costs, deduct 25
percent of that amount to document advance funds received, and pay the
balance to the Contractor.
5. Upon termination ofthis contract, the full amount of undocumented advance
funds shall become immediately due and owing to the Department.
II. The payment-in-full provided for in 1.A. above or the advance provided for in
1.c. above will be paid by no later than December 14, 2006.
In the event that the Department does not receive a properly completed contract
package from the Contractor by October 13, 2006, the payment date will be
recalculated to be no later than sixty (60) days following receipt of the properly
completed contract package.
II1. Progress payment requests as provided for in 1.B. and 1.c. above shall be
submitted to the Department's designated payment office at the following
address:
New York State Department of State
Contract Administration Unit - LMI
41 State Street / 10th Floor
Albany, New York 12231-0001
A. Payments shall be made to the Contractor upon the submission by the
Contractor of properly executed progress payment requests. Each such
request shall contain the following: (1) "Summary Sheet Documentation
Forms" as provided by the Department, for documentation of actual and
eligible expenditures; (2) a narrative progress report describing in detail all
significant project accomplishments for which reimbursement is claimed,
with dates of completion (NOTE: If this agreement is for the purchase of
tangible goods, commodities or equipment only, a narrative is not
required for payments; however, a listing of all items purchased and
dates received must be detailed on the Summary Sheet Documentation
Forms.); and (3) a properly completed Standard Voucher.
B. Notwithstanding the above requirements, upon written notification by the
Department, the Contractor may be required to submit source documentation
and additional verification of allowable expenditures.
C-4
C. Payment requests as described in III.A. above shall be certified by a duly
authorized representative of the Contractor as accurately representing such
accomplishments and expenses as recorded in the Contractor's accounting
records, including, where goods or services are provided by third parties not
party to this Agreement, a certification that any payment obligations arising
from the provision of such goods or services have been paid by the
Contractor and do not duplicate reimbursement or costs and services received
from other sources.
D. Claimed expenditures per cost category may exceed the amounts indicated
in the Budget, Appendix B, by ten percent (10%) or $1,000, whichever is
greater, without approval of the Department, provided that the Funding
Amount is not exceeded. Any expenditure in excess of such 10% or $1,000
shall require an amendment to the Project Budget submitted in writing by the
Contractor. No expenditures shall be allowed for items not set forth in the
Project Budget without prior written approval of the Department.
E. Any payment request for any period during which all Project activities shall
have been completed shall be submitted as the Contractor's final payment
request and shall be clearly labeled FINAL.
I. If a final progress narrative report is required to be submitted, it must
describe in reasonable detail, the nature and degree of the Project's
completion and results.
2. If the Contractor has received prior payments exceeding total eligible
expenditures, Contractor shall remit such excess to the Department with
such FINAL request.
IV. Notwithstanding the submission of timely and properly executed payment
requests, the Department shall be under no obligation to make payment for
expenditures incurred without the prior Department approvals and/or
amendments required under this Agreement and, further, shall have the right to
withhold any such payment pending the execution of such approval and/or
amendment.
A. Interest income earned on funds received pursuant to this Agreement shall be
used to further the purpose of this Project or shall be deducted from total
eligible costs to determine the net eligible costs to be reimbursed by the
Department.
C-5
,
B. The Department shall have the right to conduct on-site progress assessments
and reviews of the Project and Contractor's books and records during the life
of this Agreement and for a reasonable time following issuance of the FINAL
payment.
C. The Department shall be entitled to disallow any cost or expense, or
terminate or suspend this Agreement, if found that the Contractor has
misrepresented any expenditures or Project activities in this Agreement, or
in any progress reports or payment requests made pursuant hereto.
D. The Contractor shall maintain separate fiscal books and records for all funds
received through the Department and Project activities conducted pursuant
to this Agreement, and shall make all such books and records available to the
Department, the Office of the State Comptroller, or their designated
representatives for inspection and audit for a period of six (6) years following
termination of this Agreement.
D-I
APPENDIX D
Pro grain W orkplan
Recipient Organization Name: 'l'own of Southo1d
Program Contact Person: James McMahon
Daytime Phone: 631) 765-1283
Fax: (6311 765-9015
Typ~eq. Initiat ve
.
NARRATIVE
(MUST BE COMPLETED FOR ALL PROJECT TYPES AND PAYMENT OPTIONS)
NOTE: If payment Option A: Payment-In-Full for completed project was selected, make sure that
this Narrative complies with Section 3 of Option A.
Th.e Town of Southold will contract with Leslie-Johnson Corp.
to IDstalI (2) School Speed Limit Flashing Sign Units, in the vicinity
of the Greenport School, on Route 25, Greenport, NY.
(A TT ACH ADDITIONAL PAGES AS NEEDED)
E-I
APPENDIX E
CHARITIES AND CHARITABLE TRUSTS
Most not-far-profit organizations (including corporations and charitable trusts) are
required to file annual financial reports with the Attorney General. This requirement is
found in Article 7-A of the Executive Law and Article 8 of the Estates, Powers and
Trusts Law (EPTL). Specifically, Section 8-1.4 of the EPTL states:
(a) For the purposes of this section, "trustee" means (1) any individual, group of
individuals, corporation or other legal entity holding and administering property for
charitable purposes, whether pursuant to any will, other instrument or agreement, court
appointment, or otherwise pursuant to law, over which the attorney general has
enforcement or supervisory powers, (2) any non-profit corporation organized under the
laws of this state for charitable purposes, and (3) any non-profit foreign corporation
organized for charitable purposes, doing business or holding property in this state.
Neither a foreign corporation nor a trustee acting under the will of, or any agreement
executed by, anon-resident of this state shall become subject to the provisions of this
section merely by reason of maintaining a bank, custody, investment or similar account
in this state.
(s) A trustee shall not be qualified to make application for funds or grants or to receive
such funds from any department or agency of the state without certifYing compliance
with paragraphs (d), (t), and (g) of this section and all applicable registration and
reporting requirements of Article 7-A of the Executive Law.
In addition, please note that the new Charities Registration number is a 6-digit number
with a hyphen after the second and fourth digits.
Pages E-2 and E-3 contain the inclusive listing of exemptions to the registration and
reporting requirements of each article oflaw cited above.
If the Contractor qualifies for exemption from either article of law, place the complete
number, i.e., 2(b), of the exemption in the respective section of Box 4 on the Contract
Face Page.
Any questions regarding the statutory requirements or applicability to your organization
should be directed to:
Office of the Attorney General
Charities Registration Bureau
120 Broadway
New York, New York 10271
212-416-8400 / 212-416-8401
E-2
CHARITIES REGISTRATION EXEMPTIONS
EXECUTIVE LAW, ARTICLE 7-A
1. This article shall not apply to corporations organized under the religious corporations law, and other
religious agencies and organizations, and charities, agencies, and organizations operated, supervised, or controlled by
or in connection with a religious organization.
2. The following persons shall not be required to register with the attorney general:
(a) An educational institution confining its solicitation of contributions to its student body, alumni, faculty and
trustees, and their families.
(b) Fraternal, patriotic, social, alumni, law enforcement support organizations and historical societies chartered
by the New York state board of regents when solicitation of contributions is confined to their membership.
I!:>) Persons requesting any contributions for the relief of any individual, specified by name at the time of
solicitation, if all of the contributions collected, without any deductions whatsoever, are paid to or for the benefit ofthe
named beneficiary.
(d) Any charitable organization which does not intend to solicit and receive and does not actually receive
contributions in excess of twenty-five thousand dollars during a fiscal year of such organization, provided none ofits
fund raising functions are carried on by professional fund raisers or commercial co-venturers. However, if the gross
contributions received by such charitable organization during any fiscal year of such organization shall be in excess of
twenty-five thousand dollars, it shall within thirty days after thedate it shall have received total contributions in excess
oftwenty-five thousand dollars register with the secretary as required by section one hundred seventy-two of this article.
(e) Any charitable organizationreceiving an allocation from a federated fund, incorporated community appeal
or a united way, provided such fund, appeal or united way is complying with the provisions ofthis article relating to
registration and filing of annual reports with the secretary, and provided such organization does not actually receive,
in addition to such allocation, contributions in excess of twenty-five thousand dollars during the fiscal year, and
provided further that all the fund-raising functions of such organizations are carried on by persons who are unpaid for
such services. However, if the gross contributions other thansuch allocation received by such charitable organization
during any fiscal year of such organization shall be in excess oftwenty-five thousand dollars, it shall within thirty days
after the date it shall have received such contributions in excess of twenty-five thousand dollars register with the
secretary as required by section one hundred seventy-two of this article.
(f) A local post, camp, chapter or similarly designated element, or a county unit of such elements, of a bona
fide veterans' organization which issues charters to such local elements throughout this state, a bona fide organization
of volunteer firemen, an organization providing volunteer ambulance service (as defmed in section three thousand one
of the public health law) or a bona fide auxiliary or affiliate of such organizations, provided all its fund-raising activities
are carried on by members of such an organization or an affiliate thereof and such members receive no compensation,
directly or indirectly, thereof.
(g) An educational institution which files annual financial reports with the regents of the university ofthe state
of New York as required by the education law or with an agency having similar jurisdiction in another state or library
which files annual financial reports as required by the state education department.
(h) A charitable organization which receives all or substantially all of its funds from a single governmental
agency and reports annually to that agency provided such reports contain financial information substantially similar in
content to that required by subdivision one of section one hundred seventy-two-b ofthis article; provided, however, that
such organization may receive no more than twenty-five thousand dollars from sources other than the government
agency to which it reports.
(1) Any police department, sheriffs department or other governmental law enforcement agency.
(j) The state parent teachers association and any parent teachers association affiliated with an educational
institution that is subject to the jurisdiction of the state education department.
3. In addition to the statutory exemptions, the following are also exempt:
(a) Any Municipality.
(b) Fire Districts, School Districts, and Water Districts.
E-3
CHARITABLE TRUSTS REPORTING EXEMPTIONS
EST A TES, POWERS AND TRUSTS LAWS
EXECUTIVE LAW, ARTICLE 8, SECTION 8-1.4(b)
The registration and reporting provisions of this section do not apply to:
1. Contractor is not a Trustee as define in Section 8-1.4(a) set forth in Appendix E.
2. Government entity
3. Entity required by law to complete an annual report to either the United States Congress or the
New York State Legislature;
4. Religious organizations;
5. Educational institution incorporated under the Education Law or by special act;
6. Hospital;
7. Fraternal, patriotic, social, student, alumni, veterans, volunteer firefighters, volunteer
ambulance workers' organization or historical society chartered by the New York State Board
of Regents;
8. Trust or estate for which there is a corporate trustee acting as sole trustee or co-trustee under
the will of a decedent who died domiciled outside New York or a trust instrument executed by
a nonresident of New York State;
9. Trust or estate in which the charitable interest is delayed or contingent;
10. Officer, director or trustee of an organization exempt from registration who holds property for
the religious, educational or charitable purposes of the organization;
I I. Cemetery corporation subject to the provisions of Article 15 of the Not-for-Profit Corporation
Law;
12. The state parent teachers association ("PT A") and any parent teachers association affiliated with
an educational institutional that is subject to the jurisdiction of the State Education Department;
and
13. Any corporation organized under Article 43 of the Insurance Law.
APPENDIX X
Agency Code
Contract Period
Contract Number
Funding for Period
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the New York State
Department of State, having its principal office in Albany, New York (hereinafter referred to as the STATE), and
(hereinafter referred to as the CONTRACTOR), for modification of Contract
Number , as amended above.
All other provisions of said AGREEMENT shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under
their signatures.
CONTRACTOR SIGNATURE
By:
STATE AGENCY SIGNATURE
By:
(print name)
(print name)
Title: Title:
Date: Date:
State Agencv Certification: "In addition to the acceptance of this Contract, I also certify that original copies of this signature
page will be attached to all other exact copies of this Contract. n
STATE OF NEW YORK )
COUNTY OF ) ss:
On this _ day of , in the year 20_, before me personally appeared
,to me known, who, being byme duly sworn, did depose and say
that (s)he resides at ; that (s)he is the
~ ,~
corporation described herein which executed the foregoing instrument; and that (s)he signed (her)his name thereto
by order of the board of directors of said corporation.
NOTARY PUBLIC
STATE OF NEW YORK )
COUNTY OF ) ss:
On this _ day of , in the year 20_, before me personally appeared
, to me known and known to me to be the
of , the
unincorporated association described in and which executed the above agreement; and who acknowledge to me that
(s )he executed the foregoing agreement for and in behalf of said unincorporated association.
NOTARY PUBLIC
ALAN G. HEVESI, STATE COMPTROLLER
Title:
Date:
AL,; Y<' (Hev, 6194)
STATE
OF
NEW YORK
STANDARD VOUCHER
Voucher No.
~ Originating Agency
lori9
I asc Use Only
I Zip Code
Agency Code
Interest Eligible (YfN)
fH;;"~/O ~(,
(YY)
Payment Date (MM) (DO) (YY)
I I
~ Payee 10 Additional
( 1- (;,nr,,9"59
141 Payee Name (Limit to 30 spaces)
r-' Town of Southold
liability Date
(MMI
(DO)
I
I Route
Payee Amount
I MIA Dale (MM) (001 (YY)
I I I
IRS Code
IRS Amount
Payee Name (Limit 10 30 spaces)
Stat. Type
Statistic
Indicator-Dept.
Itndicator-Statewlde
AddP((J~030;.g:>< ( (rJ (
A~;(~tl;;rcesAir:l;/7 If cI
5~tl;,2~;~S~ ( ri (LimitlO 2 spaces) -> INY IZ/rcr7f_ 0?J7
~ PUfchase Descliption 01 Malerial/Service
Order No. 11 ilems are 100 numerous to be incorporaled into the block below,
and Date use Form AC 93 and carry lotal forward
~ Ref/lnv. No. (Limit to 20 spaces)
Ref/lny. Date
(MM) (DO) (YY)
I I
Quantity Unil
Price
Amounl
F{~Sh!:!J
G--~l1ffY(+
+v~ -#~L (J7~1- H
S c-!toO( D;s-frr'q
1:H'7(S-CV~OC
-
2J paye.e certiflcation~: .,.
I certify Ihat ~he above blllt I, true and correct: that no part thereof has been paid except as stated and that
the balance IS actually d d owing, an~t taxes from which the Slate is exempt are excluded.
.....310. ,1 ~.L;, _. Supervisor
"I' h ~ "",H',Slgnoto,";nlnk Town of SOU:;Old
~Dot~
Total -
Discount
%
Name of Company
Net
FOR AGENCY USE ONL Y
STATE COMPTROLLER'S PRE-AUDIT
Cer1ified For Payment
01
Net Amount
Verified
Merchandise Received
Date
I certily that this voucher is correc! and just, and payment is approved. and the goods or services
rendered or furnished are lor use in the performance 01 the oHicial functions and duties of this
agency
Page No
Authorized Signature
Audiled
B,
Date
Title
Special Approval
(as Required)
B,
Var Yr
Object
Expenditure
Accum
oept. Statewide
Liquidation
Cost Center Code
Dept. Cosl Center Unit
Amounl
Orig. Agency
PO/Contract
Une
F/?
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Check if Continuation
lorm is attached.
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