State of Connecticut

This page was last updated on: April 15, 2011

REQUEST FOR PROPOSAL (RFP)
UNEMPLOYMENT COMPENSATION ADMINISTRATION

COMPTROLLER'S GIFT AFFIDAVIT
TO ACCOMPANY CONTRACTS FOR SERVICES FOR STATE EMPLOYEES

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 a 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. 1-79(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 or a member of the Vendor Advisory Committee 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 an officer, employee or agent of myself or the company/firm who participated directly, extensively and substantially in the preparation of the response to this request for proposal know of any action taken to circumvent this vendor affidavit disclosure.

I, or a principal or key personnel of the company/firm participating in the preparation of the response to the request for proposals has, in the two years preceding the submission of this response to a request for proposals given the following campaign contributions to a member of the general assembly or a candidate for statewide office.

________________________________________________________________________________

________________________________________________________________________________

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