State of Connecticut

This page was last updated on: April 15, 2011

 STATE OF CONNECTICUT 
OFFICE OF THE STATE COMPTROLLER

REQUEST FOR PROPOSAL

HEALTH BENEFITS CONSULTING SERVICES

Bid / Proposal Affidavit

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