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Request for Application (RFA) AppendicesKentucky Governor’s Office of Early Childhood

Appendix A - Checklist for the 2018-2019 Community Early Childhood Council (CECC) Request for Application (RFA)

Applicants shall submit all the following components for the CECC funding opportunity. Applications missing any component will not be considered and the applicant will be asked to resubmit.

Contact information for the Fiscal Agent using the Fiscal Agent Contact Information Form. The Form can be accessed using the following link: https://kidsnow.ky.gov/communities/cecc/Pages/cecc-resources.aspx

Application Cover Page with Notary Seal Project Summary Summary of Previous Activities (Not applicable for new CECCs.) Community Needs Narrative Strategic Plan Narrative Work Plan Communication Plan Budget Narrative and Budget Preliminary Members List is due with submission of the application. The Preliminary Members List shall include

a list of all partner agencies on the CECC. At least one representative from each of the following entities must be included on the CECC: o Local agency or organization from profit, nonprofit or family child care;o Head Start or Early Head Start;o Each school district in the CECC’s designated service area.The Final Members List is due to the GOEC May 1, 2018.

Letters of Commitment from three required community partners Conflict of Interest Form for each Council member Original copy mailed to the GOEC as well as an electronic copy submitted to the GOEC via Dropbox W-9 (if required) Affidavit (if required)

CECC Funding ApplicationApplication Deadline: February 13, 2018

Applications postmarked after this date will not be considered.

CECCs shall submit the completed application and documentation to Dropbox. CECCs shall create a Dropbox account, save their application documents to Dropbox, and email a Dropbox link from their Dropbox account to [email protected] to provide the GOEC access to application documents no later than February 13, 2018. If for any reason the applicant cannot utilize a Dropbox account, please contact Diana Hutch at [email protected].

CECCs shall also mail the original application and documentation to:Kentucky Governor’s Office of Early Childhood

c/o Diana Hutch125 Holmes Street, Third Floor

Frankfort, KY 40601

mailto:[email protected]


https://kidsnow.ky.gov/communities/cecc/Pages/cecc-resources.aspx


Mailed copies must be postmarked no later than February 13, 2018.Appendix B – Cover Page

Council Name: ______________________________________ Total Pages: _______________

Counties Served: ____________________________________ Total Membership: _________

Chair Information

Chair Name: _________________________________________________________________________

Address: ____________________________________________________________________________

Phone Number: ______________________________________________________________________

Email: ______________________________________________________________________________

Fiscal Agent

Fiscal Agent Name: ___________________________________________________________________

Organization: __________________________________ Org Type _____________________________

Tax ID (Federal): ___________________________ Tax ID (State): ______________________________

Address: ____________________________________________________________________________

Phone: _____________________________________________________________________________

Email: ______________________________________________________________________________

Is your Council a 501c3 Yes________ No________

The undersigned agree to ensure the funds awarded by this grant will be used to complete the plans outlined in this application and achieve School Readiness for children in the service area.

___________________________________________ Date: ___________________Community Early Childhood Council Chair

___________________________________________ Date: ___________________Community Early Childhood Council Fiscal Agent

Notary Public __________________________________________

My commission expires on: _____________________ Notary Seal


Appendix C – Conflict of Interest Statement

I, the undersigned, acknowledge and confirm that in carrying out my duties as a director, officer or member of The Governor’s Office of Early Childhood Community Early Childhood Council (CECC), a non-profit organization, I am charged with a duty of loyalty and fiduciary accountability to the CECC. To this end, I acknowledge my responsibilities to act in the course of my duties solely in the best interest of the CECC, without consideration of the interests of any other person or organization and to refrain from taking part in any transaction where I do not believe in good faith that I can with undivided loyalty to the CECC.

I shall disclose to the Council any potential conflict of interest I may have from time to time, including the identification of any material, financial or other beneficial interest held by me or by my immediate family in organizations engaged in the same business or services as the CECC or engaged in the delivery of products or services to the CECC. I shall also disclose any transaction with the CECC which would result in any benefit to me, my immediate family, or any organization in which I have a material financial or other beneficial interest or involvement, and I shall refrain from participation in any action on such matters, except to the extent permitted by the Conflict of Interest Policy.

I shall not disclose or exploit for any personal advantage, or for the advantage of any other organization in which I have an interest or involvement, any confidential information acquired by me regarding CECC business activities or plans. Further, I will abstain from CECC votes impacting organizations in which I have interest or involvement.

Pursuant to the above, I hereby report that I have an interest or involvement as an owner, partner, director, trustee, officer, employee, or agent of, or that I or my spouse, parents, children, or spouses of children, brothers or sister, or spouses of brothers or sister or any combination of them, have a material financial interest (greater than 5% ownership) or any other beneficial interest in:

1. The following organizations engaged in the same or substantially similar businesses or services as the Community Early Childhood Council.

a. Name:

Interest or Involvement

b. Name:


2. The following organizations engaged in the delivery of products or services to the corporation:

c. Name:


d. Name:


I assume the duty of notifying the Community Early Childhood Council, in writing, of any changes in or additions to the information disclosed in this Disclosure Statement.

Signature:

Printed Name: ______________________________________ Date:


Appendix D – Evaluation of ApplicationIndependent reviewers with content expertise will review and score applications. Reviewers may include Child Care Resource and Referral staff, early childhood specialists, higher education faculty, and other qualified individuals. Reviewers will score and provide comments to the Early Childhood Advisory Council, which will be used to determine award recipients. Applications will be evaluated according to the extent that they meet the following criteria.

CRITERIA MAXIMUM POINTSREQUIRED COMPONENTSApplicants must include ALL of the following to be considered: Summary of Previous Activities (if applicable) Signed and notarized Cover Page Preliminary Members List with a list of all partnering agencies serving on the CECC. At least one

representative from each of the following entities must be included on the CECC: Local agency or organization from profit, nonprofit or family child care, Head Start or Early Head Start and each school district in the CECC’s designated service area.

Letters of Commitment from the following required interest groups: child care, all Head Start(s) and/or Early Head Start(s) grantees in the service area, and all local school district(s) within the service area. School districts must have a Letter of Commitment signed by the Superintendent or School Board Chair.

Signed Conflict of Interest Statements from each member

Included?

0COMMUNITY NEEDS NARRATIVEApplicants shall clearly: Describe the service area’s existing resources as well as the availability, quality and

participation of early care and education programs within the service area. Demonstrate how the CECC will achieve the School Readiness Goals. Demonstrate how the CECC plans to promote community partnerships.

10 10

10

30STRATEGIC PLAN Supported by Work Plan DocumentApplicant shall clearly: Identify achievable outcomes aligned to School Readiness Goals, School Readiness Strategies

and community needs based on data review and analysis Demonstrate how outcome(s) will lead to school readiness Indicate how proposed activity(s) will lead to successful outcomes Demonstrate clear collaboration between CECC and community partners Create a detailed Work Plan using the Work Plan Template with all required information

provided to ensure proposed activities are successful

1010101010

50BUDGET NARRATIVE AND BUDGETThe budget shall reflect: Provided templates with categories on GOEC website Reasonable fiscal resources to support implementation of the plan, including cost of proposed

activities Leveraging of other community resources, either through monetary or in-kind contributions, to

further outcomes Local or private funding commitments

55

5

520

TOTAL POINTS 100


Appendix E – RFA Budget Template

Please complete the CECC grant budget using the Budget Template below.

Expense Description Amount Requested In-Kind MatchBudget Items Describe purpose of budget items

below. Please outline the who, what, when, and where of each expenditure

$3,000.00 $2,000

Personnel/Fringe Benefits – (Hourly rate x # of hours) and/or total amount of consultant fees

Click here to enter text. $Click here to enter text. $Click here to enter text.

Travel – Total estimated expenditures


Supplies/Material/Equipment – Estimated number and cost of items


Administrative – Limited to 5% of requested amount


Other Click here to enter text. $Click here to enter text. $Click here to enter text.

Total Requested Amount $ Click here to enter text.


Appendix F - RFA Work Plan Template

Please complete each category in the Work Plan Template on the following page. Each of the School Readiness Goals shall be chosen using the dropdown box in the Goals column below. Then, a School Readiness Strategy(s), Identified Need, Performance Indicator, Activities, Person/Partner Responsible, Timeline and Outcomes shall be included for each School Readiness Goal. One or more School Readiness Strategies can be chosen for each School Readiness Goal using the dropdown box provided.

NOTE:

The Completion Date column on the Work Plan Template is for the use of CECCs during the grant cycle. It shall not be completed with the submission of the RFA.

School Readiness Goals

CECCs are asked to focus on the following School Readiness Goals:

1. Increasing awareness and participation in Kentucky ALL STARS;2. Increasing family engagement and support opportunities;3. Increasing awareness of school readiness;4. Increasing the number of children, particularly those at risk, participating in high quality early care and education programs.

School Readiness Strategies

To achieve the listed School Readiness Goals, four main strategies have been identified which are the focus of system efforts:

1. Improving the quality of all early care and education programs;2. Engaging families as their child’s first and most important teachers;3. Engaging the community to promote school readiness;4. Enhancing the ability to measure the impact of the work by improved data collection and integration.


Please complete the Work Plan using the Work Plan Template below.

Work Plan Template

School Readiness Goal Identified Need

School Readiness Strategy

Performance Indicators Activities Person/Partner

Responsible Timeline Completion Date Outcomes

Example: Increasing awareness and participation in Kentucky ALL STARS

Example: Early Childhood Profile indicates only 2 of 10 child care programs participate in ALL STARS

Example: Improving the quality of all early care and education programs

Example: Increase number of child care programs participating in ALL STARS

Example: Outreach to non-participating child care centers;Developing of mentoring relationships

Example: John and Sue

Example: Aug. 2018-Dec. 2018

Example: December 19, 2018

Example: Participation in ALL STARS increased from two child care programs in the service area to five child care programs in the service area.

Choose a School Readiness Goal.

Choose a School Readiness Strategy.


Choose a


School Readiness Strategy.








Appendix G - RFA Preliminary Members List

The Preliminary Members List is due with the submission of the application.

Per KRS 200.707, “A council shall be composed of no fewer than seven (7) and no more than twenty-seven (27) members. Each council shall be composed of at least one (1) member representing local agencies or organizations from profit, nonprofit or family child care, Head Start or Early Head Start and each school district in its designated service area. Other members may be appointed who represent local agencies and organizations, including, but not limited to, the organizations or agencies listed: Early childhood advocate; Faith community; Family resource center; Military establishment; Child-care resource and referral agency or child-care subsidy agent; Child-care consumer or parent; County cooperative extension service; Department for public health; University, college, or technical school; United Way; Kentucky Early Intervention System; Agency administering services to children with disabilities; Home visitation agency; Family literacy agency; Civic organization; Public library; Regional training center; Community action agency; Government; Business community; Home schooling association; Health care professional; Foster care parent; or Adoptive parent.”

In accordance with KRS 200.707(2), “Members shall serve on a community early childhood council on a voluntary basis and receive no compensation or expense reimbursement for their service.”

Using the table below, please provide the type of partnering agency as well as the name of the specific agency, organization or school district represented by each CECC member.

Type of Partnering Agency Name of Specific Agency, Organization or School DistrictChoose an item.Choose an item.

Choose an item.

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Appendix H - Final Members List

*The Final Members List shall be submitted to the GOEC via Dropbox.

Per KRS 200.707, “A council shall be composed of no fewer than seven (7) and no more than twenty-seven (27) members. Each council shall be composed of at least one (1) member representing local agencies or organizations from profit, nonprofit or family child care, Head Start or Early Head Start and each school district in its designated service area. Other members may be appointed who represent local agencies and organizations, including, but not limited to, the organizations or agencies listed: Early childhood advocate; Faith community; Family resource center; Military establishment; Child-care resource and referral agency or child-care subsidy agent; Child-care consumer or parent; County cooperative extension service; Department for public health; University, college, or technical school; United Way; Kentucky Early Intervention System; Agency administering services to children with disabilities; Home visitation agency; Family literacy agency; Civic organization; Public library; Regional training center; Community action agency; Government; Business community; Home schooling association; Health care professional; Foster care parent; or Adoptive parent.”

In accordance with KRS 200.707(2), “Members shall serve on a community early childhood council on a voluntary basis and receive no compensation or expense reimbursement for their service.”

The Final Members List shall also include the following additional information: the county or counties each member represents and the date of appointment for each CECC member as well as their length of term.

Per KRS 200.707(3)(a), “Members shall serve for a term of two (2) years and until their successors are appointed, except that for those members initially appointed, the terms shall be as follows:

1. One-third (1/3) of the members shall be appointed for three (3) years; 2. One-third (1/3) shall be appointed for two (2) years; and 3. One-third (1/3) shall be appointed for one (1) year.

(b) Vacancies shall be appointed for unexpired terms in the same manner as original appointments.”


Please submit the Final Members List using the template below. CECCs shall create a Dropbox account, save their document in Word document format to Dropbox, and email a Dropbox link from their Dropbox account to [email protected] to provide GOEC access to the Final Members List no later than May 1, 2018. If for any reason the applicant cannot utilize a Dropbox account, please contact Diana Hutch at [email protected]. Please make sure your Final Members List is complete before submitting it to the GOEC.

Final Members List Template

First Name

Last Name

Place of Employment Agency

Is this member a required

representative from Child Care, Head Start/Early

Head Start or School

District?

Phone Email Member Role

County/Counties Represented

Date of Appointment

Length of Term

First Name

Last Name

Choosean item.

Choose an item.

(502) 555-5555

Click here to enter text.

Choosean item.

First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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First Name

Last Name

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(502) 555-5555


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Last Name

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Last Name

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(502) 555-5555


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Last Name

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Last Name

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Appendix I- Maximum Award Amount by CountyEach county is listed with their Education and Work Force Development Area.

Amounts subject to change according to availability of funds.

CountyUnder Age 5 Population

20162018-19 Maximum Award Amount

Adair County, Cumberlands 1020 $ 8,000.00Allen County, South Central 1296 $ 8,000.00Anderson County, Blue Grass 1311 $ 8,000.00Ballard County, West Kentucky 407 $ 5,000.00Barren County, South Central 2889 $ 20,000.00Bath County, Tenco 860 $ 7,000.00Bell County, EKCEP 1648 $ 12,000.00Boone County, Northern Kentucky 8784 $ 25,000.00Bourbon County, Bluegrass 1212 $ 8,000.00Boyd County, TENCO 2946 $ 20,000.00Boyle County, Bluegrass 1640 $ 12,000.00Bracken County, TENCO 546 $ 6,000.00Breathitt County, EKCEP 821 $ 7,000.00Breckinridge County, Lincoln Trail 1142 $ 8,000.00Bullitt County, Kentuckianaworks 4189 $ 22,000.00Butler County, South Central 762 $ 7,000.00Caldwell County, West Kentucky 750 $ 7,000.00Calloway County, West Kentucky 1962 $ 12,000.00Campbell County, Northern Kentucky 5454 $ 25,000.00Carlisle County, West Kentucky 327 $ 5,000.00Carroll County, Northern Kentucky 806 $ 7,000.00Carter County, EKCEP 1732 $ 12,000.00Casey County, Cumberlands 1017 $ 8,000.00Christian County, West Kentucky 6930 $ 25,000.00Clark County, Bluegrass 2113 $ 16,000.00Clay County, EKCEP 1303 $ 8,000.00Clinton County, Cumberlands 617 $ 6,000.00Crittenden County, West Kentucky 563 $ 6,000.00Cumberland County, Cumberlands 411 $ 5,000.00Daviess County, Green River 6762 $ 25,000.00Edmonson County, South Central 569 $ 6,000.00Elliott County, EKCEP 352 $ 5,000.00Estill County, Blue Grass 801 $ 7,000.00Fayette County, Bluegrass 19899 $ 35,000.00Fleming County, TENCO 962 $ 7,000.00Floyd County, EKCEP 2279 $ 16,000.00Franklin County, Bluegrass 2893 $ 20,000.00Fulton County, West Kentucky 374 $ 5,000.00


Gallatin County, Northern Kentucky 512 $ 6,000.00Garrard County, Bluegrass 954 $ 7,000.00Grant County, Northern Kentucky 1839 $ 12,000.00Graves County, West Kentucky 2457 $ 16,000.00Grayson County, Lincoln Trail 1695 $ 12,000.00Green County, Cumberlands 573 $ 6,000.00Greenup County, TENCO 1954 $ 12,000.00Hancock County, Green River 606 $ 6,000.00Hardin County, Lincoln Trail 7200 $ 25,000.00Harlan County, EKCEP 1773 $ 12,000.00Harrison County, Bluegrass 1087 $ 8,000.00Hart County, South Central 1250 $ 8,000.00Henderson County, Green River 2827 $ 20,000.00Henry County, Kentuckianaworks 879 $ 7,000.00Hickman County, West Kentucky 228 $ 5,000.00Hopkins County, West Kentucky 2791 $ 20,000.00Jackson County, EKCEP 800 $ 7,000.00Jefferson County, Kentuckianaworks 48616 $ 50,000.00Jessamine County, Bluegrass 3517 $ 22,000.00Johnson County, EKCEP 1409 $ 12,000.00Kenton County, Northern Kentucky 11096 $ 35,000.00Knott County, EKCEP 898 $ 7,000.00Knox County, EKCEP 2054 $ 16,000.00Larue County, Lincoln Trail 779 $ 7,000.00Laurel County, Cumberlands 3652 $ 22,000.00Lawrence County, EKCEP 1066 $ 8,000.00Lee County, EKCEP 360 $ 5,000.00Leslie County, EKCEP 639 $ 6,000.00Letcher County, EKCEP 1351 $ 8,000.00Lewis County, TENCO 757 $ 7,000.00Lincoln County, Bluegrass 1507 $ 12,000.00Livingston County, West Kentucky 517 $ 6,000.00Logan County, South Central 1688 $ 12,000.00Lyon County, West Kentucky 258 $ 5,000.00Madison County, Bluegrass 5109 $ 22,000.00Magoffin County, EKCEP 761 $ 6,000.00Marion County, Lincoln Trail 1252 $ 8,000.00Marshall County, West Kentucky 1695 $ 12,000.00Martin County, EKCEP 591 $ 6,000.00Mason County, TENCO 1040 $ 8,000.00McCracken County, West Kentucky 3853 $ 22,000.00McCreary County, Cumberlands 1043 $ 8,000.00McLean County, Green River 557 $ 6,000.00Meade County, Lincoln Trail 1419 $ 12,000.00


Menifee County, EKCEP 338 $ 5,000.00Mercer County, Bluegrass 1258 $ 8,000.00Metcalfe County, South Central 631 $ 6,000.00Monroe County, South Central 667 $ 6,000.00Montgomery County, TENCO 1845 $ 12,000.00Morgan County, EKCEP 672 $ 6,000.00Muhlenberg County, West Kentucky 1658 $ 12,000.00Nelson County, Lincoln Trail 2937 $ 20,000.00Nicholas County, Bluegrass 435 $ 5,000.00Ohio County, Green River 1406 $ 8,000.00Oldham County, Kentuckianaworks 3314 $ 22,000.00Owen County, Northern Kentucky 537 $ 6,000.00Owsley County, EKCEP 267 $ 5,000.00Pendleton County, Northern Kentucky 868 $ 7,000.00Perry County, EKCEP 1827 $ 12,000.00Pike County, EKCEP 3323 $ 22,000.00Powell County, Bluegrass 821 $ 7,000.00Pulaski County, Cumberlands 3649 $ 22,000.00Robertson County, TENCO 115 $ 5,000.00Rockcastle County, Cumberlands 917 $ 7,000.00Rowan County, TENCO 1325 $ 8,000.00Russell County, Cumberlands 1103 $ 8,000.00Scott County, Bluegrass 3483 $ 22,000.00Shelby County, Kentuckianaworks 3088 $ 22,000.00Simpson County, South Central 1137 $ 8,000.00Spencer County, Kentuckianaworks 1045 $ 8,000.00Taylor County, Cumberlands 1593 $ 12,000.00Todd County, West Kentucky 857 $ 7,000.00Trigg County, West Kentucky 741 $ 6,000.00Trimble County, Kentuckianaworks 487 $ 5,000.00Union County, Green River 803 $ 7,000.00Warren County, South Central 8033 $ 25,000.00Washington County, Lincoln Trail 751 $ 6,000.00Wayne County, Cumberlands 1133 $ 8,000.00Webster County, Green River 848 $ 7,000.00Whitley County, Cumberlands 2692 $ 20,000.00Wolfe County, EKCEP 413 $ 5,000.00Woodford County, Bluegrass 1478 $ 8,000.00

Source: U.S. Census. (2017). Annual estimates of resident population by selected age groups 2010-2016.


Appendix J- W-9

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

orNote. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Under penalties of perjury, I certify that:1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Date ▶

Signature ofU.S. person ▶

Sign Here

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Prin

t or t

ype

See

Spe

cific

Inst

ruct

ions

on

page

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:Individual/sole proprietor or C Corporation S Corporation Partnership Trust/estate single-member LLCLimited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) Requester’s name and address (optional)

6 City, state, and ZIP code

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Social security number

– –

Employer identification number

–

Part II Certification


Appendix K- Affidavit Solicitation/Contract #: _________________________

REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS PAGE 1 OF 2

FOR BIDS AND CONTRACTS IN GENERAL:

I. Each bidder or offeror swears and affirms under penalty of perjury, that:

a. In accordance with KRS 45A.110 and KRS 45A.115, neither the bidder or offeror as defined in KRS 45A.070(6), nor the entity which he/she represents, has knowingly violated any provisions of the campaign finance laws of the Commonwealth of Kentucky; and the award of a contract to the bidder or offeror or the entity which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth.

b. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and all subcontractors therein, are aware of the requirements and penalties outlined in KRS 45A.485; have properly disclosed all information required by this statute; and will continue to comply with such requirements for the duration of any contract awarded.

c. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and its affiliates, are duly registered with the Kentucky Department of Revenue to collect and remit the sales and use tax imposed by KRS Chapter 139, and will remain registered for the duration of any contract awarded.

d. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding is not delinquent on any state taxes or fees owed to the Commonwealth of Kentucky and will remain in good standing for the duration of any contract awarded.

FOR “NON-BID” CONTRACTS (I.E. SOLE-SOURCE; NOT-PRACTICAL OR FEASIBLE TO BID; OR EMERGENCY CONTRACTS, ETC):

II. Each contractor further swears and affirms under penalty of perjury, that:

a. In accordance with KRS 121.056, and if this is a non-bid contract, neither the contractor, nor any member of his/her immediate family having an interest of 10% or more in any business entity involved in the performance of any contract awarded, have contributed more than the amount specified in KRS 121.150 to the campaign of the gubernatorial slate elected in the election last preceding the date of contract award.

b. In accordance with KRS 121.330(1) and (2), and if this is a non-bid contract, neither the contractor, nor officers or employees of the contractor or any entity affiliated with the contractor, nor the spouses of officers or employees of the contractor or any entity affiliated with the contractor, have knowingly contributed more than $5,000 in aggregate to the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract award.


REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS

c. In accordance with KRS 121.330(3) and (4), and if this is a non-bid contract, neither the contractor, nor any member of his/her immediate family, his/her employer, or his/her employees, or any entity affiliated with any of these entities or individuals, have directly solicited contributions in excess of $30,000 in the aggregate for the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract.

As a duly authorized representative for the bidder, offeror, or contractor, I have fully informed myself regarding the accuracy of all statements made in this affidavit, and acknowledge that the Commonwealth is reasonably relying upon these statements, in making a decision for contract award and any failure to accurately disclose such information may result in contract termination, repayment of funds and other available remedies under law.

Signature Printed Name

Title Date

Company Name

Address

Subscribed and sworn to before me by(Affiant) (Title)

of this _____day of ____________,20___.(Company Name)

Notary Public

[seal of notary] My commission expires:

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