State of Connecticut

This page was last updated on: June 22, 2015


I,____________________, as the company official authorized to execute the attached contract hereby swear that in the two years preceding the negotiations on this contract, neither I nor a principal or key personnel of the company/firm who participated directly, extensively and substantially in the negotiation of this contract, nor any agent of the above gave a contribution to a candidate for statewide public office or the General Assembly, as defined by C.G.S. ?9-333b, except those listed below (include candidate name, date of contribution, contributor and amount of contribution):



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