State of Connecticut

This page was last updated on: April 15, 2011

COMPTROLLERíS GIFT AFFIDAVIT
Accompanying the RFP Response

I, ___________________________________________, hereby swear that, during the two years preceding the date of this affidavit, neither I nor principals or key personnel of ______________________________ (company name) who participated directly, extensively and substantially in the preparation of this response to the request for proposal have provided or caused to be provided any gifts, as defined in Connecticut General Statutes, Section 1-79(e), except as set forth below, including a gift for the celebration of a major life event as set forth in C.G.S. ß1-79(e)(12) or any items of value for which full payment has not been made, to a state official or employee of the Office of the State Comptroller who participated directly, extensively and substantially in the preparation of bid solicitations:

Name of Recipient Value of Gift/Item Date of Gift/Item Description




Further, neither I nor any principals or key personnel, nor any agent of the above, knows of any action by _________________ (company name) to circumvent such prohibition on gifts by providing for any other principals, key personnel, officials, employees of the company, nor any agents of the above, to provide a gift, in violation of the Ethics Code, to any such public official or state employee.

Further, the Contractor made its bid or proposal without fraud or collusion with any person.

Sworn as true to the best of my knowledge and belief, subject to the penalties for a false statement.

__________________________    ___________________________    __________
Signature    Print Name    Date

Subscribed and sworn before me on this ____ day of _____________, 200_.

____________________________
Commissioner of the Superior Court/
Notary Public