Form AC3290-S "Vendor Responsibility Questionnaire for-Profit Business Entity" - New York

What Is Form AC3290-S?

This is a legal form that was released by the Office of the New York State Comptroller - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2013;
  • The latest edition provided by the Office of the New York State Comptroller;
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  • Fill out the form in our online filing application.

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AC 3290-S (Rev. 9/13)
NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE
FOR-PROFIT BUSINESS ENTITY
You have selected the For-Profit Non-Construction questionnaire which may be printed and completed in this format or, for your
convenience, may be completed online using the New York State VendRep System.
COMPLETION & CERTIFICATION
The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or officer
must certify the questionnaire and the signature must be notarized.
NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID)
The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This
number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk
at
ITServiceDesk@osc.state.ny.us
or call 866-370-4672.
DEFINITIONS
All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at
www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf. These terms may not have their ordinary, common or
traditional meanings. Each vendor is strongly encouraged to read the respective definitions for any and all underlined terms. By
submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility
Definitions List" existing at the time of certification.
RESPONSES
Every question must be answered. Each response must provide all relevant information which can be obtained within the limits of the
law. However, information regarding a determination or finding made in error which was subsequently corrected is not required.
Individuals and Sole Proprietors may use a Social Security Number but are encouraged to obtain and use a federal Employer
Identification Number (EIN).
REPORTING ENTITY
Each vendor must indicate if the questionnaire is filed on behalf of the entire Legal Business Entity or an Organizational Unit within
or operating under the authority of the Legal Business Entity and having the same EIN. Generally, the Organizational Unit option
may be appropriate for a vendor that meets the definition of “Reporting Entity” but due to the size and complexity of the Legal
Business Entity, is best able to provide the required information for the Organizational Unit, while providing more limited information
for other parts of the Legal Business Entity and Associated Entities.
ASSOCIATED ENTITY
An Associated Entity is one that owns or controls the Reporting Entity or any entity owned or controlled by the Reporting Entity.
However, the term Associated Entity does not include “sibling organizations” (i.e., entities owned or controlled by a parent company
that owns or controls the Reporting Entity), unless such sibling entity has a direct relationship with or impact on the Reporting Entity.
STRUCTURE OF THE QUESTIONNAIRE
The questionnaire is organized into eleven sections. Section I is to be completed for the Legal Business Entity. Section II requires the
vendor to specify the Reporting Entity for the questionnaire. Section III refers to the individuals of the Reporting Entity, while
Sections IV-VIII require information about the Reporting Entity. Section IX pertains to any Associated Entities, with one question
about their Officials/Owners. Section X relates to disclosure under the Freedom of Information Law (FOIL). Section XI requires an
authorized contact for the questionnaire information.
AC 3290-S (Rev. 9/13)
NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE
FOR-PROFIT BUSINESS ENTITY
You have selected the For-Profit Non-Construction questionnaire which may be printed and completed in this format or, for your
convenience, may be completed online using the New York State VendRep System.
COMPLETION & CERTIFICATION
The person(s) completing the questionnaire must be knowledgeable about the vendor’s business and operations. An owner or officer
must certify the questionnaire and the signature must be notarized.
NEW YORK STATE VENDOR IDENTIFICATION NUMBER (VENDOR ID)
The Vendor ID is a ten-digit identifier issued by New York State when the vendor is registered on the Statewide Vendor File. This
number must now be included on the questionnaire. If the business entity has not obtained a Vendor ID, contact the IT Service Desk
at
ITServiceDesk@osc.state.ny.us
or call 866-370-4672.
DEFINITIONS
All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” found at
www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf. These terms may not have their ordinary, common or
traditional meanings. Each vendor is strongly encouraged to read the respective definitions for any and all underlined terms. By
submitting this questionnaire, the vendor agrees to be bound by the terms as defined in the "New York State Vendor Responsibility
Definitions List" existing at the time of certification.
RESPONSES
Every question must be answered. Each response must provide all relevant information which can be obtained within the limits of the
law. However, information regarding a determination or finding made in error which was subsequently corrected is not required.
Individuals and Sole Proprietors may use a Social Security Number but are encouraged to obtain and use a federal Employer
Identification Number (EIN).
REPORTING ENTITY
Each vendor must indicate if the questionnaire is filed on behalf of the entire Legal Business Entity or an Organizational Unit within
or operating under the authority of the Legal Business Entity and having the same EIN. Generally, the Organizational Unit option
may be appropriate for a vendor that meets the definition of “Reporting Entity” but due to the size and complexity of the Legal
Business Entity, is best able to provide the required information for the Organizational Unit, while providing more limited information
for other parts of the Legal Business Entity and Associated Entities.
ASSOCIATED ENTITY
An Associated Entity is one that owns or controls the Reporting Entity or any entity owned or controlled by the Reporting Entity.
However, the term Associated Entity does not include “sibling organizations” (i.e., entities owned or controlled by a parent company
that owns or controls the Reporting Entity), unless such sibling entity has a direct relationship with or impact on the Reporting Entity.
STRUCTURE OF THE QUESTIONNAIRE
The questionnaire is organized into eleven sections. Section I is to be completed for the Legal Business Entity. Section II requires the
vendor to specify the Reporting Entity for the questionnaire. Section III refers to the individuals of the Reporting Entity, while
Sections IV-VIII require information about the Reporting Entity. Section IX pertains to any Associated Entities, with one question
about their Officials/Owners. Section X relates to disclosure under the Freedom of Information Law (FOIL). Section XI requires an
authorized contact for the questionnaire information.
NYS Vendor ID: ____________
AC 3290-S (Rev. 9/13)
NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE
FOR-PROFIT BUSINESS ENTITY
I. LEGAL BUSINESS ENTITY INFORMATION
Legal Business Entity Name*
EIN
Address of the Principal Place of Business (street, city, state, zip code)
New York State Vendor Identification Number
Telephone
Fax
ext.
Email
Website
Additional Legal Business Entity Identities: If applicable, list any other DBA, Trade Name, Former Name, Other Identity, or EIN
used in the last five (5) years and the status (active or inactive).
Type
Name
EIN
Status
1.0 Legal Business Entity Type – Check appropriate box and provide additional information:
Corporation (including PC)
Date of Incorporation
Limited Liability Company (LLC or PLLC)
Date of Organization
Partnership (including LLP, LP or General)
Date of Registration or Establishment
Sole Proprietor
How many years in business?
Other
Date Established
If Other, explain:
1.1 Was the Legal Business Entity formed or incorporated in New York State?
Yes
No
If ‘No,’ indicate jurisdiction where Legal Business Entity was formed or incorporated and attach a Certificate of Good Standing
from the applicable jurisdiction or provide an explanation if a Certificate of Good Standing is not available.
United States
State
Other
Country
Explain, if not available:
1.2 Is the Legal Business Entity publicly traded?
Yes
No
If “Yes,” provide CIK Code or Ticker Symbol
1.3 Does the Legal Business Entity have a DUNS Number?
Yes
No
If “Yes,” Enter DUNS Number
*
All underlined terms are defined in the “New York State Vendor Responsibility Definitions List,” which can be found at
www.osc.state.ny.us/vendrep/documents/questionnaire/definitions.pdf.
Page 2 of 10
NYS Vendor ID: ____________
AC 3290-S (Rev. 9/13)
NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE
FOR-PROFIT BUSINESS ENTITY
I. LEGAL BUSINESS ENTITY INFORMATION
1.4 If the Legal Business Entity’s Principal Place of Business is not in New York State, does the Legal Business
Yes
No
Entity maintain an office in New York State?
N/A
(Select “N/A,” if Principal Place of Business is in New York State.)
If “Yes,” provide the address and telephone number for one office located in New York State.
1.5 Is the Legal Business Entity a New York State certified Minority-Owned Business Enterprise (MBE),
Yes
No
Women-Owned Business Enterprise (WBE), New York State Small Business (SB) or a federally certified
Disadvantaged Business Enterprise (DBE)?
If “Yes,” check all that apply:
New York State certified Minority-Owned Business Enterprise (MBE)
New York State certified Women-Owned Business Enterprise (WBE)
New York State Small Business (SB)
Federally certified Disadvantaged Business Enterprise (DBE)
1.6 Identify Officials and Principal Owners, if applicable. For each person, include name, title and percentage of ownership. Attach
additional pages if necessary. If applicable, reference to relevant SEC filing(s) containing the required information is optional.
Name
Title
Percentage Ownership
(Enter 0% if not applicable)
Page 3 of 10
NYS Vendor ID: ____________
AC 3290-S (Rev. 9/13)
NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE
FOR-PROFIT BUSINESS ENTITY
II. REPORTING ENTITY INFORMATION
2.0 The Reporting Entity for this questionnaire is:
Note: Select only one.
Legal Business Entity
Note: If selecting this option, “Reporting Entity” refers to the entire Legal Business Entity for the remainder of the
questionnaire. (SKIP THE REMAINDER OF SECTION II AND PROCEED WITH SECTION III.)
Organizational Unit within and operating under the authority of the Legal Business Entity
S
“R
E
“O
U
EE DEFINITIONS OF
EPORTING
NTITY
AND
RGANIZATIONAL
NIT
FOR ADDITIONAL INFORMATION ON CRITERIA TO
.
QUALIFY FOR THIS SELECTION
Note: If selecting this option, “Reporting Entity” refers to the Organizational Unit within the Legal Business Entity for the
remainder of the questionnaire. (COMPLETE THE REMAINDER OF SECTION II AND ALL REMAINING SECTIONS OF
THIS QUESTIONNAIRE.)
IDENTIFYING INFORMATION
a) Reporting Entity Name
Telephone
Address of the Primary Place of Business (street, city, state, zip code)
ext.
b) Describe the relationship of the Reporting Entity to the Legal Business Entity
c) Attach an organizational chart
Yes
No
d) Does the Reporting Entity have a DUNS Number?
If “Yes,” enter DUNS Number
e) Identify the designated manager(s) responsible for the business of the Reporting Entity.
For each person, include name and title. Attach additional pages if necessary.
Name
Title
Page 4 of 10
NYS Vendor ID: ____________
AC 3290-S (Rev. 9/13)
NEW YORK STATE
VENDOR RESPONSIBILITY QUESTIONNAIRE
FOR-PROFIT BUSINESS ENTITY
INSTRUCTIONS FOR SECTIONS III THROUGH VII
For each “Yes,” provide an explanation of the issue(s), relevant dates, the government entity involved, any remedial or corrective
action(s) taken and the current status of the issue(s). For each “Other,” provide an explanation which provides the basis for not
definitively responding “Yes” or “No.” Provide the explanation at the end of the section or attach additional sheets with numbered
responses, including the Reporting Entity name at the top of any attached pages.
III. LEADERSHIP INTEGRITY
Within the past five (5) years, has any current or former reporting entity official or any individual currently or formerly having the
authority to sign, execute or approve bids, proposals, contracts or supporting documentation on behalf of the reporting entity with
any government entity been:
Yes
No
Other
3.0 Sanctioned relative to any business or professional permit and/or license?
Yes
No
Other
3.1 Suspended, debarred, or disqualified from any government contracting process?
3.2 The subject of an investigation, whether open or closed, by any government entity for a civil or
Yes
No
Other
criminal violation for any business-related conduct?
Yes
No
Other
3.3 Charged with a misdemeanor or felony, indicted, granted immunity, convicted of a crime or
subject to a judgment for:
a) Any business-related activity; or
b) Any crime, whether or not business-related, the underlying conduct of which was related to
truthfulness?
For each “Yes” or “Other” explain:
IV. INTEGRITY – CONTRACT BIDDING
Within the past five (5) years, has the reporting entity:
4.0 Been suspended or debarred from any government contracting process or been disqualified on any
Yes
No
government procurement, permit, license, concession, franchise or lease, including, but not limited to,
debarment for a violation of New York State Workers’ Compensation or Prevailing Wage laws or New
York State Procurement Lobbying Law?
Yes
No
4.1 Been subject to a denial or revocation of a government prequalification?
4.2 Been denied a contract award or had a bid rejected based upon a non-responsibility finding by a
Yes
No
government entity?
Yes
No
4.3 Had a low bid rejected on a government contract for failure to make good faith efforts on any Minority-
Owned Business Enterprise, Women-Owned Business Enterprise or Disadvantaged Business Enterprise
goal or statutory affirmative action requirements on a previously held contract?
Yes
No
4.4 Agreed to a voluntary exclusion from bidding/contracting with a government entity?
4.5 Initiated a request to withdraw a bid submitted to a government entity in lieu of responding to an
Yes
No
information request or subsequent to a formal request to appear before the government entity?
For each “Yes,” explain:
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