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ATTACHMENT III
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 of false statement.
| ______________________________________ | _____________________ | ______________ |
| Signature | Print Name | Date |
Subscribed and sworn before me on this______________ day of ____________, 200___
________________________________
Commissioner of the Superior Court
Notary Public