HomeMy WebLinkAboutStrawberry Fields Suffolk County SCEX Form 22
Contractor's/Vendor's Public Disclosure Statement
Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure
Statement must be completed by all contractors/vendors that have a contract with Suffolk
County. In the event contractodvendor 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 ~ O~/J O¢"
Address ~.0. ~X- ( ('~__ ~"70 ?~- ,,L,/~;,4
City and State , f ~ c&-~o (c/~ /O ~' Zip Code fl
2. Contracting Department's Name
Address
5.b
o
Payee Identification or Social Security No.
Type of Business__Corporation__Partnership__Sole Proprietorship__Other
Is contractor/vendor entering into or has contractor/vendor entered into a contract with
Suffolk County in excess of $1,0007 Yes No.
Has contractor/vendor entered into three or more contracts, including the one for which
you are now completing this form, with Suffolk County, any three of which, when
combined, exceed $1,0007 Yes No.
Table of Organization. List names and addresses of all principals; that is, all individuals
serving on the Board of Directors or comparable body, names and addresses of all
partners, and names and addresses of all corporate officers. Conspicuously identify any
person in this table of organization who is also an officer or an employee of Suffolk
County. (Attach additional sheet if necessary.)
List all names and addresses of those individual shareholders holding more than five
percent (5%) interest in the contractor/vendor. Conspicuously identify any shareholder
who is also an officer or an employee of Suffolk County. (Attach additional sheet if
necessary).
So
10.
Does contractor/vendor derive 50% or more of its total revenues from its contractual or
vendor relationship with Suffolk County?__Yes__No.
If you answered yes to 8 above, you must submit with this disclosure statemen[, a
complete financial statement listing all assets and liabilities as well as a profit and loss
statement. These statements must be certified by a Certified Public Accountant. (Strike
this out if not applicable.)
The undersigned shall include this Contractor'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,
~ exempt from completing paragraphs numbered 1 through 11 herein: pital
~bi 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 statp~nents and that they are, to his/her
own knowledge, true.
Dated: o~-q'~Ot~ Signed:
Printed Name of Signer:
Title of Signer:
Name of ContractorNendor:
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW YORK)
COUNTY OF..fa ~'~-o/.~(.ss.:
On the '~day of -~f~ in the year 201~ before me, the undersigned personally appeared
~'oo.h~4~, ~ perso~,ly known to me or proved to me on the basis of satisfactory evidence
to be the individual(X) whose nameO0 is Car-*) subscribed to the within instrument and acknowledged to
me that he~.t~executed the same in his~ capacity(i~) and that by his/hor/Xkc/r signature('~
on the instrument, the individual04), or the person upon behalf of which the individual(~ acted, executed
the instrument.
(signature and office of individual taking acknowledgment)
LYNDA
NOTARY PUBLIC, State of New York
NO. 01R[16020932, Suffolk County
Term Expires March 8, 20 II
Page 2 of 2 Public Disclosure Form
Rev. '10/12/2010