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Affirmation of financial responsibility for public contracts, March 1998

Machine-extracted title · confidence 95%

Legal affirmation form declaring no arrears to the City of New York required for receiving public contracts.

NYC-WTC_000170732–000170734

Folder label: “Affirmation”

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NYC 9/11 Public Portal Document

CGS COMMISSIONER’S OFC TEL:212-669-8992 Mar 05’98 IS:36 No. 00? P.02 AFFIRMATION

The undersigned Landlord, Lessor, Licensor or Optionor affirms and declares (hat said Landlord, Lessor, Licensor or Optionor is not in arrears to the City of New York upon debt, contract or taxes and is not a defaulter, as surety or otherwise, upon obligations to the City of New York, and has not been declared not responsible, or disqualified, by any agency of the City of New York, nor is there any proceeding pending relating to the responsibility or qualification of the proposer or bidder to receive public contracts except

Full nttmc of Landloi d, Lessor, Licensor or Optionor:

Address.

City. State Zip Code.

CHECK ON BOX AND INCLUDE APPROPRIATE NUMBER [ ] A - Individual or Sole Proprietorship* SOCIAL SECURITY NUMBER

f ] B ■ Partnership, Joint Yenturc or other unincorporated Organization EMPLOYER IDENTIFICATION NUMBER

11 C - Corporation EMPLOYER IDENTIFICATION NUMBER

Signature of an Officer or Duly Authorized Representative

Title Date

If a corporation place seal here:

Under the Federal Privacy Act the furnishing of Social Security Numbers by Individuals on City City contracts is voluntary. Failure to provide a Social Security Number will not result in an individual’s uisquaiirication. social Security Numbers wiii be used to identify Landlords, ijessors. Licensors nr Optionors, to ensure their compliance with laws, to assist the City in enforcement of laws, as well as to provide the City a means of identifying businesses which seek City contracts.

FOR DCAS ONLY:

Agency Address IPIS Number

NYC-WTC_000170732

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NYC-WTC_000170732Source: NYC Law Department, mirrored locally

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