This page was last updated on: June 22, 2015
Gift/Campaign Contribution Affidavit to Accompany Bid or
Proposal
for Large State Contracts, Pursuant to Sections 2, 3 and 4 of Public Act 04-245
and Governor M. Jodi Rell?s Executive Order No. 1, para 8.
I, Type/Print Title and Name of Firm or Corporation hereby swear that during the two-year period preceding the submission of this bid or proposal that neither myself nor any principals or key personnel of the submitting firm or corporation who participated directly, extensively and substantially in the preparation of this bid or proposal nor any agent of the above gave a gift, as defined in Conn. Gen. Stat. ?1-79(e), including a life event gift as defined in Conn. Gen. Stat. ?1-79(e)(12), to (1) any public official or state employee of the state agency or quasi-public agency soliciting the bids or proposals who participated directly, extensively, and substantially in the preparation of the bid solicitation or preparation of request for proposal or (2) to any public official or state employee who has supervisory or appointing authority over the state agency or quasi-public agency soliciting the bid or proposal, except the gifts listed below:
| Name of Benefactor | Name of recipient | Gift Description | Value | Date of Gift |
|---|---|---|---|---|
| List information here |
||||
Further, neither I nor any principals or key personnel of the submitting firm or corporation who participated directly, extensively and substantially in the preparation of this bid or proposal know of any action to circumvent this gift/campaign contribution affidavit.
Further, during the two-year period preceding the submission of this bid or proposal, neither I nor any principals or key personnel of the submitting firm or corporation who participated directly, extensively and substantially in the preparation of this bid or proposal nor any agent of the above gave a contribution to a candidate for statewide public office or the General Assembly, as defined in Conn. Gen. Stat. ?9-333b, except as listed below:
| Contributor | Recipient | Amount/Value | Date of Contribution | Contribution Description |
|---|---|---|---|---|
| List information here |
||||
Sworn as true to the best of my knowledge and belief, subject to the penalties of false statement.
_______________________________________ |
_________________________ |
| Signature | Date |
Sworn and subscribed before me on this______________ day of ____________, 200___
________________________________
Commissioner of the Superior Court
Notary Public