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Home My WebLink AboutNorth Fork Audubon Society - Office Space at Inlet Pond . RESOLUTION 2005-607 ADOPTED DOC ID: 1181 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2005-607 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON SEPTEMBER 27,2005: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Joshua Y. Horton to execute the License Al!reement between the Town of Southold and the North Fork Audubon Society. Inc. for the use of office space at Inlet Pond Park for a period of one year with an automatic renewal for a successive one year period, subject to the approval ofthe Town Attorney. P4rUfQ!?~:tIA. Elizabeth A. Neville South old Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Louisa P. Evans, Justice SECONDER: Thomas H. Wickham, Councilman AYES: Edwards, Ross, Wickham, Romanelli, Evans, Horton Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement must be completed by all contractors/vendors that have a contract with Suffolk County. In the event contractor/vendor is exempt from completing paragraphs numbered 1 through 11 below, so indicate at paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt status, you must execute this form below before a notary public. 1. Contractor'sNendor's Name .-( () u-ll'\. 0 f- A?dress (,0, (J,o)(-J.!c)~ [;iD 1"- H/Af/\ City and State 5.o1A_~_ __ Contracting Department's Name' Address Payee Identification or Social Security No. Type of Business_ Corporation_Partnership_ Sole Proprietorship_Other Is contractor/vendor entering into or has contractor/vendor entered into a contract with Suffolk County in excess of $1 ,OOO? _Yes_No. 5.b Has contractor/vendor entered into three or more contracts, including the one for which you are now completing this form, with Suffolk County, any three of which, when combined, exceed $1 ,OOO? _Yes_No. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Board of Directors or comparable body, names and addresses of all partners, and names and addresses of all corporate officers. Conspicuously identify any person in this table of organization who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary.) 2. 3. 4. 5.a 6. Suffolk County SCEX Form 22 Contractor'sNendor's Public Disclosure Statement 50 LA+l.DIJ Ad, Zip Code I' 9 /f (-n ?31 7. List all names and addresses of those individual shareholders holding more than five percent (5%) interest in the contractor/vendor. Conspicuously identify any shareholder who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary). 8. Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor relationship with Suffolk County? _Yes_No. 9. If you answered yes to 8 above, you must submit with this disclosure statement, a complete financial statement listing all assets and liabilities as well as a profit and loss statement. These statements must be certified by a Certified Public Accountant. (Strike this out if not applicable.) 10. The undersigned shall include this Contractor'sNendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.) Page 1 of 2 Public Disclosure Form 11. Remedies. The failure to file a verified public disclosure statement as required under local law shall constitute a material breach of contract. Suffolk County may resort, use or employ any remedies contained in Article II of the Uniform Commercial Code of the State of New York. In addition to all legal remedies, Suffolk County shall be entitled, upon a determination that a breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract. 12. If you are one of the entities listed below at a) through c) or you qualify under d) below, you are exempt from completing paragraphs numbered 1 through 11 herein: a) Hospital ~ b) Educational or governmental entities c) Not-for-profit corporations d) Contracts providing for foster care, family day-care providers or child protective services Please check to the left side of the appropriate exemption. 13. Verification. This section must be signed by an officer or principal of the contractor/vendor authorized to sign for the company for the purpose of executing contracts. The undersigned being sworn, affirms under the penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to his/her own knowledge, true. 'r4' / ..;/ / Dated: (-.:J.a,-O( Signed: '.J-::~~ Printed Name of Signer: ') ('.0 +4. "l1. ~ Title of Signer: -.S::.'-< ,,;;lP,4 (;j ) fY1 Name of ContractorNendor:/o Vr ) ^ ..., -+- 50 VI. +h ,0 ! rI UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: ( On the ~ day of '-..T"", b1 U(:vt~ in the year 2008 before me, the undersigned personally appeared k -o+f- /( ,.(;, (r"f! personal y known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to we that he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed Ir11~t~u~e. \: ~ e and office of individual taking acknowledgment) KIERAN M. CORCORAN QUALlFIEO IN SUFFOLK COUNTY NOTARY #02C06119838 MY COMMISSION EXPIriES DEC. 6, 24 Page 2 of 2 Public Disclosure Form Rev. 1/4/2008 1ff](.J~' [~Jn~~.:(~I-lrUr<'I;I\ !IlJ_ .1 ...." J/llI SU/,fllVISOIfS'C>>i'iiT ](JlVN or SOIJTHOlD COUNTY OF SUFFOLK STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF PARKS, RECREATION AND CONSERVATION JOHN W. PAVACIC COMMISSIONER TRACEY BELLONE DEPUTY COMMISSIONER January 4, 2008 Honorable Scott Russell Town of Southold Supervisor P.O. Box 1179 Southold, NY 11971 Re: Inlet Pond County Park Dear Supervisor Russell, Pursuant to your License Agreement with Suffolk County, all Licensees, including not-for-profits, are contractually required to provide a Contractor'sNendor's Public Disclosure Statement (attached) on or before January 31st of each year of their Agreement with the County of Suffolk. Failure to provide said statement may constitute a material breach of the Agreement for which the County shall be entitled to damages, in addition to all other legal remedies, of fifteen percent (15%) of the amount of the Agreement. Attention is called specifically to questions number 8 and 9 on the form. If your firm derives 50% or more of its total revenue from your relationship with Suffolk County, be advised that a complete Financial Statement, certified by a Certified Public Accountant, listing all assets and liabilities as well as a profit and loss statement, must be submitted. Please forward a completed, notarized disclosure form to the Contracts Unit to my attention, or if you have any questions, feel free to call me at 854-4918. Sincerely, ~~~- {)-~ce~ Angela ;J. Guarino Contracts Examiner Attachment cc: John W. Pavacic, Commissioner Tracey Bellone, Deputy Commissioner Mary Ellen Houghtalen, Senior Contracts Examiner Scott Stocker, Auditor MONTAUK HIGHWAY - P.O. BOX 144 WEST SAYVILLE, NEW YORK 11796.0144 (631) 854-4949 FAX: (631) 854-4977 . .~ii.J"j~.F<.>LiC C<~VNTY PARKS