Common use of Iran Divestment Act Compliance Clause in Contracts

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public APT E- See Footer Tax ID #: APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: Project Title/ Agency PIN # See Contract Cover Page Footer Response Date See Article 1 Contracting Agency Department of Transportation Buildings Agency Address New York City New York State NY Zip 000 Xxxxxxxx, 0xx Xxxxx Xxxx Xxx Xxxx Xxxxx XX Xxx Code 10041 10007 Contact Person Xxxxxx Xxxxxx X. Wong Title Director of M/WBE Program & Oversight Deputy Agency Chief Contracting Officer Telephone # (000) -000-0000 Email xxxxxxxx@xxx.xxx.xxx xxxxxx@xxxxxxxxx.xxx.xxx Project Description (attach additional pages if necessary)) Group Percentage Unspecified N/A% or Women N/A% Total Participation Goals See Schedule A% Line 1 APT E- See Footer Tax ID #: PIN #:

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: M/WBE UTILIZATION FORMS FILLABLE FORM APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)) Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Tax ID #: FILLABLE FORM

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000028 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000029 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000027 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Xitle Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000063 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer 81018B0002 APT E- Pin # See Footer 81018B0002 FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation PIN # Microfiche Storage, Retrieval, and Duplication Agency Address New York City New York State NY 000 Xxxxxxxx Xxxx Xxx Xxxx Xxxxx XX Zip Code 10041 10007 Contact Person Xxxxxx Xxxxxx Xxxxx Xxxxxxxxx Title Director of M/WBE Program & Oversight Procurement Attorney Telephone # (000) -000-0000 Email xxxxxxxx@xxx.xxx.xxx xxxxxxxxxx@xxxxxxxxx.xxx.xxx Project Description (attach additional pages if necessary)) Storage, retrieval, and duplication as needed of the Department of Buildings microfiche records.

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)) Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Tax ID #: APT E- PIN #:

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000028 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Part A, Article 1 A Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)) Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000035 APT E-PIN #: See Footer APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Response Date See Part A, Article 1 A Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary)) Unspecified See Total Participation Goals below or Black American N/A % Hispanic American N/A % Asian American N/A % Women N/A % Total Participation Goals See Schedule A for % Line 1 Tax ID #: PIN #: