office of children and family services dormitory authority funding for voluntary agency capital project comprehensive applicatio

OFFICE OF CHILDREN AND FAMILY SERVICES
DORMITORY AUTHORITY FUNDING
FOR VOLUNTARY AGENCY CAPITAL PROJECT
COMPREHENSIVE APPLICATION PACKET
December 2005
GENERAL INSTRUCTIONS FOR COMPLETING THE
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COMPREHENSIVE APPLICATION PACKET
Please read the instructions for completion of each form to avoid an
incomplete submission.
CP-1 - General Information: Self-explanatory
CP-2 - Staffing Summary
Please submit a form for the group residence or institution program
affected by the proposed project.
Please note that this listing is by job title. Individual positions
should not be listed separately. Staff FTEs should be reported on a
12-month basis calculated in accordance with the usual Standards of
Payment rules for reporting FTEs.
CP-3 - Description of Current Physical Plant
Please complete a separate form for each building currently used by
the residential program that will be using this source of funding.
CP-4 – Estimated Project Cost
Please submit estimated project costs in the format provided. Use the
comment column for specifying "other" descriptions and/or to provide
additional details pertaining to the cost estimate.
CP-5 - Projected Financial Impact on Facility Costs
Complete a separate form for each residential program affected by the
proposed project. Only include facility-related costs that may change
as a direct result of the project. Specify the fiscal period for the
Standards of Payment report that these costs were taken from.
Estimated annual facility costs should account only for any actual
increase/decrease and should not take any inflationary factors into
consideration. (Updated estimates may be requested at a later time.)
CP-6 - Checklist of Documents Required for Submission of Application
Please submit the required documents, as indicated.
Attachments
Final Certification in Support of a Voluntary Agency’s Comprehensive
Application for Dormitory Authority Financing – Please complete.
Listing of Referral Sources in Support of Capital Project Financing –
Please complete.
Revised Guidelines for Determining Depreciation of a Capital Project
These instructions are a replacement of existing guidelines in the
Standards of Payment Manual regarding the cost reporting and
reimbursement rules for a capital project.
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Overview of Tax Exempt Financing Process for DASNY Financing
Vendor Responsibility Questionnaire – Please complete.
FORM CP-1 - General Information
1) Legal Name of Agency:
_______________________________________________________
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2) A/K/A, if applicable:
_______________________________________________________
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3) Executive Director’s Name:
____________________________________________________
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4) Mailing Address:
_____________________________________________________________
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(Administrative Offices)
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5) Telephone: __________________________________________
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6) Fax: __________________________________________
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7) Contact Person:
- Name, Title, and Phone Number:
_______________________________________________
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________________________________________________________________
8) Agency Location (Administrative Offices)
- if different from mailing address:
_________________________________________________
_______________________________________________________________________________
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9) Street Address of Project:
______________________________________________________
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10) Legal Name of the Owner of the Property (where project is to be
located):
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11) Project Description (describe purpose and scope of project):
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12) Please describe the Agency’s existing long term (with a term of
more than 1 year) debt by providing the following information with
respect to each loan:
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Amount of outstanding debt / Lender / Security for the Loan / Term –
when is it due
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13.
Explain how the project will benefit the health and safety of the
children served or to be served by the current program or new
program. Describe population of current or new program, as
appropriate.
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13.
Complete the following in regard to the population to be served by
the proposed project:
a) Licensed capacity* that will result from this project: __________
b) Current capacity in program affected by this project: __________
c) Anticipated care days in first year of operation following project:
__________
* The total capacity of the institution program for which this project
is being proposed may not
exceed the total licensed capacity currently approved.
13.
Provide answers to the following in regard to the proposed
project:
a.
Type of project (e.g. replacement building, addition,
alteration/renovation, site development)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
b.
Type of facility (e.g., group residence or institution)
______________________________________________________________________
______________________________________________________________________
c.
Size of project (gross floor area, size of site, number of rooms,
number of beds, etc.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
d.
If applicable, describe any changes in outdoor facilities on
agency property as a result of the capital construction project.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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FORM CP-2 Staffing Summary
For those staff in program affected by proposed project, report all
such staff by job title, including staff that does not change as a
result of this capital construction project. (Staff with the same job
title should be grouped together and not listed individually.)
Agency/Program Name:
__________________________________________________________
Program Type (institution or group residence):
_______________________________________
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Current Rate for Existing Program (if it will be affected by proposed
project): $___________
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JOB TITLE
FTE
BEFORE CONSTRUCTION*
COST CATEGORY DIRECT/NON DIRECT CARE
FTE AFTER
CONSTRUCTION/ RENOVATION*
* FTEs should be reported as 12 month FTEs.
Agency Name: ____________________________________
Project Site: _____________________________________
FORM CP-3 – Description of Current Physical Plant
Complete this form for each existing building that will be affected by
proposed project. Please photocopy as many of these forms as you need.
Building Name:
___________________________________________________________________
Site Location:
_____________________________________________________________________
Is this building rented or owned?
1) Year constructed _______________ 4) Number of floors
_______________
2) Total square footage_______________ 5) Number of rooms per floor
3) Total square footage allocated to: 6) Number of exits per floor
_____________
a) Residential _______________
b) Other ____________________
7) How will this building be affected by the proposed project:
____________________________
________________________________________________________________________________
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8) Are areas designated as program space used for other purposes? Yes
________ No ________
If yes, please describe:
__________________________________________________________
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9) This building contains the following: (Check all that apply)
a) Bedrooms _____ f) Sprinkler system ________
b) Lunchroom/Cafeteria _____ g) Fire Alarm System ________
c) Kitchen _____ h) Smoke alarm system _____________
d) Dining room ________ i) Program accessibility for physically
handicapped
e) Recreational facilities ________ j) Toilets accessible for the
physically handicapped
k) Other (Please describe): ____________________
Agency Name: ____________________________________
Project Site: _____________________________________
FORM CP-4 - Estimated Project Cost
DESCRIPTION
NEW CONSTRUCTION
RENOVATION
COMMENT
A1. General Construction
$
$
A2. Heating, Plumbing, Electric
A3. Other (Specify):
A4. Total Building Costs (A1-A3):
$
$
B1. Architect/Engineer Fees
B2. Construction Management
B3. General Administration/Legal and Insurance
B4. Site Purchase & Development
Land Purchase
Parking Areas
Walkways
Landscaping
Other (Specify)
B5. Utilities and Service
B6. Furniture & Equipment
(Please attach a detailed listing)
B7. Other
Demolition
Project Contingency
Other (Specify)
B8. Total Incidental Costs (B1-B7)
$
$
C1. Total Building & Incidental Costs (A4+B8)
$
$
C2. Total Project Costs (New Construction + Renovation)
$
Agency Name: ____________________________________
Project Site: _____________________________________
FORM CP-5 - Projected Financial Impact on Facility Costs
For each program affected by the proposed project, complete the
following to demonstrate how the project will increase/decrease the
annual facility related costs. Please use the most recent Standards of
Payment (SOP) submission to complete this information. Only facility
costs should be included.
PROGRAM
FACILITY COST DESCRIPTION
ACTUAL ANNUAL FACILITY-RELATED COSTS REPORTED ON MOST RECENT SOP
Report *
ESTIMATED ANNUAL FACILITY-RELATED COSTS AFTER PROJECT COMPLETION
Maintenance Salaries
$
$
Maintenance Fringe Benefits
Utilities
Rent
Maintenance Supplies
Facility-Related Repairs and Maintenance
Property Insurance
Real Estate Taxes
Other (Specify)
* Specify below the period of the most recent SOP Submission used as
the basis for specifying the above figures:
SOP Submission for the period of:
July 1, _______________ through June 30, _______________________
Agency Name: ____________________________________
Project Site: _____________________________________
FORM CP-6 (CHECKLIST AND SIGNATURE PAGE)
Checklist of Required Documents for Submission of Comprehensive
Application
DOCUMENT
CP-1 General Information
CP-2 Staffing Summary
CP-3 Description of Current Physical Plant
CP-4 Estimated Project Cost
CP-5 Projected Financial Impact on Facility Costs
CP-6 (Comprehensive Application) Checklist and Signature Page
CPA Reports for the past three years (include any new reports issued
since completion of Initial Application
Final Certification(s) in Support of a Voluntary Agency’s
Comprehensive Application for Dormitory Authority Financing
Listing of Referral Sources in Support of DASNY Financing
Vendor Responsibility Questionnaire
Floor Plans and Site Plans (if required)
Code Citation Report (if required)
Line Drawings *
* Provide a copy of line drawings of the proposed floor plans (need
not be blueprint quality). These drawings need to include room labels,
the square footage of each room and the number of beds. For all
spaces, specify the specific type of space (e.g. office, kitchen,
dining room, bedroom, etc.) and the number of staff designated for
that area. If any room will serve multi-functioning purposes (e.g.
multi-purpose room) please provide an attachment detailing the
different uses.
I certify that I have examined the comprehensive application packet
and that it is a true and complete statement of the required
information.
Signature _________________________________________ Date:
__________________
Executive Director
A complete submission consisting of the documents specified above
should be sent to the following address:
Address Information
# Copies
NYS Office of Children and Family Services
Rate Setting Unit
52 Washington Street, 314 South
Rensselaer, New York 12144-2796
1
For programs licensed by OCFS, please send a copy of proposal to the
applicable OCFS Regional Office, as follows:
OCFS Regional Offices
BRO Linda Brown, (716) 847-3145, [email protected]
RRO Linda Kurtz, (585) 238-8200, [email protected]
SRO Jack Klump, (315) 423-1200, [email protected]
ARO Glenn Humphreys, (518) 486-7078, [email protected]
NYCRO Fred Levitan, (212) 383-1788, [email protected]
YRO Pat Sheehy, (914) 377-2080, [email protected]
1
For programs licensed by the NYS Office of Mental Retardation and
Developmental Disabilities, or other New York State agency, please
send a copy of proposal to the applicable office representing that
agency.
1
Final Certification in Support of an Agency’s
Comprehensive Application for DASNY Financing
This final certification is being submitted in support of the below
named agency’s comprehensive application for a capital improvement
project using the DASNY financing mechanism authorized by Chapter 472
of the Laws of 2004. I understand that in submitting this
certification, I am registering my district’s final support for the
public need of the program identified by the below named agency as
well as for the capital project that the agency is proposing to the
State for the purpose of improving its residential program.
In signing this final certification, I further understand that if this
capital project is approved, OCFS would establish an annual capital
financing add-on rate that is over and above the established maximum
State aid rate; that said add-on rate would cover the approved capital
costs associated with any foster children and Committee on Special
Education (CSE) children placed in the applicable program; that said
add-on rate would be effective for the term of the bond that is issued
to support the financing of the project; that for foster care
placements, the State would reimburse each referring social services
district at 50 percent of the DASNY add-on rate, net of any available
federal funding for those costs that exceed the social services
district’s foster care block grant allocation; and that for CSE
placements, the existing formulas for reimbursing CSE maintenance
would be applicable to the DASNY add-on rate.
I ___________________________________hereby certify
that________________________________
Commissioner or Other Official (print) Name of District (print)
supports the ___________________________________ in its final
application for approval of a capital
Name of Voluntary Agency (print)
project for the program referenced by said agency in its attached
letter of _____________________.
Date of Letter
I further certify that I am not aware of any ongoing investigations by
governmental or non-governmental entities regarding concerns about the
program or fiscal operations of the agency referenced above.
_____________________________________ ______________________________
Commissioner or Other Official’s Signature Date Signed
Listing of Referral Sources in Support of Comprehensive Application
for Capital Project Financing
Name of Voluntary Agency
________________________________________________________
Please use the following format to specify the referral sources in
support of the affected program for Capital Project financing,
including the number of children represented by each referral source.
This listing should be inclusive of all referral sources at the time
of the application. Use additional sheets as needed.
Name of Referral Source
Number of Children in Program from each Referral Source
_____________________________________ ____________________________
Agency Executive’s Signature Date Signed
Revised Guidelines for Determining and Reporting Depreciation of a
Capital Project
Standards of Payment Program Manual (Revision to Chapter 4, Section C)
Account 38 - Use Charges: Reimbursement in the maximum State aid rate
for the use of owned property (i.e., for buildings, for capital
improvements, for equipment, and for other capitalized items), as well
as for leasehold improvements, will be made through depreciation.
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*
Assets having a cost of $1,000 or more and a useful life of 2
years or more must be depreciated. Conversely, items having a unit
cost less than $1,000 or a useful life of less than 2 years may be
expensed.
APPLICABLE REGULATION (the following references in this regulation to
“department” should be interpreted to mean “OCFS”, which is the
successor agency to the State Department of Social Services):
442.4 Buildings and equipment.
(a) Definitions. As used in this section, the following definitions
shall apply:
1.
Building means a structure.
2.
Construction means the erection of a new structure.
3.
Addition means extension or increase in area, height or equipment
of an existing structure.
4.
Substantial modification means any alteration, change,
rearrangement or reconstruction to an existing structure or
equipment except for ordinary repairs and maintenance.
5.
Equipment means fixtures or articles affixed to the structure.
6.
Occupancy means use of a building, structure or premises;
abandonment or vacating a building or a major part of a building
shall be considered a change in occupancy.
b.
Construction, addition, substantial modification and change in
occupancy.
1.
Except for buildings or parts of building used in the operation of
a child caring institution, in substantial compliance with
applicable requirements on October 31, 1964, on and after November
1, 1964, no building and no part of a building shall be used for
the care of children except with the approval in writing of the
department. To qualify for approval by the department, the
building or part thereof to be used must be in substantial
compliance with the appropriate provisions of the State Building
Construction Code relating to institutions, the regulations of the
department, and all other applicable provisions of State and local
laws, ordinances, rules and regulations.
2.
There shall be no construction, addition, substantial modification
or change in occupancy of buildings or parts of buildings used or
to be used in the operation of a child caring institution, except
on plans and designs approved in writing by the department. Plans
shall be submitted for approval in accordance with the procedure
prescribed by the department thereof. To qualify for approval by
the department, plans and specifications must be in substantial
compliance with the appropriate provisions of the State Building
Construction Code relating to institutions, the regulations of the
department and all other applicable provisions of State and local
laws, ordinances, rules and regulations.
3.
No changes or modifications shall be made to approved plans or
specifications without the approval of the department.
4.
The approval of the department shall become void one year after
given unless a contract for the approved construction or
reconstruction shall have been entered into.
b.
Exceptions. The department may grant an exception to compliance
with one or more of the provisions of this section upon finding
that compliance will result in undue hardship to an institution,
that, but for the exception, the facility is in substantial
compliance with such provisions, and that granting the exception
will not create any hazardous conditions which could impair the
health or safety of the children; provided however, that the
facility otherwise complies with any alternate requirements which
the department may consider necessary for the protection of the
health or safety of the children.
Proposals for construction, addition, or substantial modification, as
those terms are defined above, and including the acquisition of
buildings, must be submitted to the OCFS Regional Office and the OCFS
Rate Setting Unit for review and approval.
Costs of facility acquisition or construction shall be depreciated
over the expected useful life of the facility per the rules and
guidelines specified below. The cost of facility acquisition or major
renovation includes architect and inspection fees, which should be
included in the cost of the building for depreciation purposes.
Renovations or alterations that are considered to be directly related
to the program and therefore reimbursable through depreciation charges
over the estimated useful life of the renovation or alteration may
include: the installation of safety devices, such as fire exits,
alarms or smoke detectors in existing buildings; the replacement of
roofs, boilers, plumbing systems, or other renovations needed to
protect the agency’s physical plant, or to protect the health or
safety of children, or to satisfy compliance with applicable New York
State standards.
For cost reporting purposes, the submission of back-up details
regarding depreciation expenses for assets such as buildings,
equipment and vehicles are not required. However, the service provider
is required to maintain depreciation schedules that include the
following minimum information:
*
Description of Asset
*
Date of Acquisition
*
Cost at Acquisition
*
Government Grants for Asset
*
Salvage Value
*
Depreciation Method
*
Useful Life Used for Depreciation Purposes
*
Annual Depreciation Amount
*
Accumulated Depreciation
Charges for depreciation must be supported by adequate property
records, and physical inventories must be taken at least once every
two years (a statistical sampling basis is acceptable) to ensure that
assets exist and are usable and needed. When the depreciation method
is followed, adequate depreciation records indicating the amount of
depreciation taken each period must also be maintained.
General Rules Regarding the Calculation of Depreciation: The following
general rules shall apply for the calculation and reporting of
depreciation expenses:
*
The computation of depreciation must be based on the acquisition
cost of the assets involved. The acquisition cost of a donated
asset must be its fair market value at the time of the donation.
*
The computation of depreciation will exclude:
*
the cost of land;
*
any portion of the cost of buildings and equipment borne by or
donated by the Federal Government irrespective of where title was
originally vested or where it presently resides; and
*
any portion of the cost of buildings and equipment contributed by
or for the non-profit organization in satisfaction of a statutory
matching requirement.
*
The period of useful service (useful life) for purposes of
establishing a depreciation schedule must take into consideration
the following factors:
*
type of construction and nature of use;
*
nature of the equipment used;
*
technological developments in the particular program area; and
*
the renewal and replacement policies followed for the individual
items or classes of assets involved.
*
Group purchases of like items should be treated as a single
purchase. Group purchases of unlike items must be treated as if
each item was purchased individually. Telephone systems and
computer systems should be treated as a group purchase.
*
The depreciable base would be calculated by taking the total cost
of the asset and by subtracting the salvage value and the amount
funded by government grants. For example, if 100 percent of the
cost of an asset is separately financed with State or Federal
grants, the asset cannot be depreciated in the SOP report for
purposes of establishing the State aid rate for an associated
program. This would need to be a reconciling item between the SOP
and the service provider’s financial statements. The portion of
the cost of building construction, acquisition, or renovation
funded by a government grant cannot be reimbursed again through
depreciation of these costs. The asset cost must be reduced by the
amount of the grant(s) and the balance depreciated in accordance
with the guidelines specified below.
*
Depreciating assets that are shared among programs/sites or among
program/sites and administration should be allocated by a
reasonable basis. Documentation for the allocation basis must be
available upon request. The “straight line method” of depreciation
must be used for all classes of assets. Use of the one-month,
six-month, or full-year convention is acceptable. When assets are
shared by multiple programs funded by more than one New York State
agency, the rules of majority funding shall dictate.
*
Depreciation based on reappraisals designed to increase the cost
basis for depreciation is not reimbursable. Accumulated
depreciation on assets transferred due to a change in legal status
of the owner, such as incorporation, is not reimbursable.
Accumulated depreciation on property owned by a division,
subsidiary or affiliate of an entity prior to acquisition by the
entity will not be reimbursed to the program after acquisition.
The remaining non-depreciated cost of the prior entity must be
reimbursed over the remaining useful life of the asset as if no
ownership change occurred.
*
Depreciation charged for assets acquired through approved
Dormitory Authority of the State of New York (DASNY)
construction/renovation projects must be reported in a separate
cost center, inasmuch as it is not reimbursable within the regular
program cost center for rate setting purposes.
*
During the construction phase of a capital project, only loan
interest and amortization of closing costs will be reimbursable in
the maximum State aid rate established by OCFS. After the agency
takes occupancy of the building, depreciation of the total capital
project would be reimbursable in the rate, within the context of
the approved rate base.
Depreciation periods for assets acquired on or after July 1, 2005:
When calculating depreciation of an asset, the useful life minimums
specified below will apply, though longer depreciation periods may be
appropriate within the context of the projected useful life and the
annual reimbursement available through the maximum State aid rate.
Exceptions to the minimums are also possible where the service
provider can justify that an alternative is more appropriate.
For example, when calculating depreciation of a building (which could
include construction, addition, or substantial modification, as those
terms are defined above, a composite approach may be used as the basis
for requesting an alternative to the standard specified below. This
means, a building's shell may be segregated from each building
component (e.g., plumbing system, heating, and air conditioning
system, etc.) and each item depreciated over its estimated useful
life; or the entire building (i.e., the shell and all components) may
be treated as a single asset and depreciated over a single useful
life. As stated above, documentation regarding useful lives used in
the determination of depreciation schedules must be maintained by the
agency and must be available upon request.
Capitalized Items Useful Life Minimums
Buildings
*
Masonry/Concrete 25 years
*
Other Materials 20 years
Land Improvements
*
Utilities / Land Management Systems 20 years
*
Landscaping / Paving 10 years
Equipment
*
Fixed (affixed to the structure) 10 years
*
Movable 5 years
Furniture 5 years
Vehicles 3 years
Technology 3 years
Amortization
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For cost reporting purposes, the submission of back-up details
regarding the amortization of assets related to intangible assets,
leasehold improvements, and mortgage expenses are not required.
However, the service provider is required to maintain amortization
schedules that include the following minimum information:
*
Description of Item
*
Beginning Date of Amortization
*
Length of Amortization
*
Costs to be Amortized
*
Accumulated Amortization
*
Current Year Amortization
The following general rules apply for the calculation and reporting of
amortization expense:
*
Leasehold improvements that are the responsibility of the service
provider under the terms of a lease should be amortized over the
useful life of the improvements or the remaining term of the
lease, whichever is shorter.
*
Mortgage expenses for purchasing or constructing a facility such
as attorney’s fees, recording costs, transfer taxes, and service
charges such as finder’s fees and placement fees, should be
amortized over the term of the mortgage.
Depreciation periods for assets acquired prior to July 1, 2005:
The following guidelines, as previously specified in the Standards of
Payment Manual, will continue to be applicable to assets acquired
prior to July 1, 2005.
Buildings:
*
Institutions and Group Residences 40 years
*
Group Homes and Agency Boarding Homes 25 years
Land Improvements 20 years
Furniture and Equipment 10 years
Vehicles 3 to 5 years
Leasehold 5 to 15 years
CHAPTER 472 OF THE LAWS OF 2004
OVERVIEW OF TAX EXEMPT FINANCING PROCESS
Chapter 472 of the Laws of 2004 of the State of New York (“Chapter
472”) authorizes the Dormitory Authority of the State of New York
(“Authority”), to issue a total of up to $30,000,000 in bonds for the
purpose of financing the renovation, equipping or replacement of
existing residential facilities for children. The purpose of this
summary is to provide potential applicants (referred to as
“borrowers”) with a general overview of the debt issuance process and
the specific requirements of Chapter 472 related to the issuance of
debt.
Tax-exempt financing is subject to the requirements of state law, as
well as both federal tax and securities law, and as a result can be
extremely complex for those not familiar with the process. Even though
these requirements will not apply to the initial application process,
your agency will be required to comply with them if it is determined
to be eligible for financing under this program. Therefore, we thought
it would helpful to give you a brief overview of these requirements.
Official Intent Requirement
Federal tax law provides that a recipient of tax-exempt bond proceeds
may not use the proceeds of the bonds to reimburse itself for
expenditures incurred prior to the issuance of the bonds unless
certain requirements are satisfied. One of these requirements is that
a borrower declare its “official intent” to reimburse itself from bond
proceeds before the expenditures are made. A declaration of official
intent typically takes the form of a resolution of the board of
directors of a borrower and need only contain a general functional
description of the applicable project.
It is strongly recommended that any agency interested in applying for
a loan under Chapter 472 not incur any significant expenditures until
it has first adopted a declaration of official intent. For those
agencies that have already incurred expenditures for which they expect
to be reimbursed, it will be necessary for the Authority’s bond
counsel to review your agency’s resolution (or other evidence of
intent) and supporting data to determine whether the requirements of
federal tax law are satisfied.
Tax Questionnaire
The Authority’s bonds will be issued as tax-exempt “qualified
501(c)(3) bonds” under federal tax law. Therefore, bond counsel must
conclude that each borrower is a 501(c)(3) organization and that the
project costs are “qualifying” costs under the Internal Revenue Code.
To confirm that the requirements of tax law are satisfied, bond
counsel will require each borrower to complete a “tax questionnaire.”
Among other things, this questionnaire will elicit information and
supporting documentation from the borrowers regarding their corporate
formation and governance as well as the character and use of its
facilities (including any contracts or other agreements that permit
their use by third parties).
SEQRA
The authorization of bonds by the Authority to fund projects of the
borrowers constitutes an “action” under the State Environmental
Quality Review Act (“SEQRA”). Therefore, the Authority must comply
with requirements of SEQRA before its board adopts financing
documents.
In order for the Authority to initiate the SEQRA review, each borrower
must complete an environmental assessment form (“EAF”) for each
project to be financed. The review process for minor renovations is
generally quite simple and requires the completion of a Short EAF. For
new construction projects, or where otherwise deemed appropriate by
the Authority, the completion of a Long EAF is required. It may be
possible to simplify the SEQRA review process if another governmental
agency, such as a local planning or zoning board, will also be
required to conduct a SEQRA review in connection with the project and
that agency and the Authority coordinate their respective reviews.
Official Statement / Due Diligence
In order to enable the Underwriter to market bonds to potential
investors, the Authority is required to prepare an Official Statement.
The Official Statement will include a description of the bonds and the
purposes for which they are being issued.
The preparation of the Official Statement is the responsibility of the
Authority. The borrowers, however, will have responsibility for
providing certain information required to be included in this
document. Specifically, the borrowers must provide the Authority with
a short description of their programs, sources of funding, and certain
financial information. Each borrower will also be required to disclose
any litigation, investigation, or other proceeding that could
materially adversely affect its operations. Each borrower must provide
the Authority with its most recent audited financial statements and
its auditor’s consent to publish the audited financial statements in
the Official Statement. Also, depending on the nature of the financial
information included in the Official Statement, the borrower, working
with the underwriter’s counsel, may be required to obtain a
“procedures letter” from its auditor regarding the auditor’s review of
the borrower’s financial information in the Official Statement.
The Underwriter’s counsel will also request various documents from the
borrowers (some of which will also be requested in the tax
questionnaire) as part of its “due diligence” process. The Underwriter
and its counsel will also meet with the borrowers, either by phone or
in person, to conduct due diligence interviews.
TEFRA Hearing
A portion of the Internal Revenue Code, known as the “Tax Equity and
Fiscal Responsibility Act” or “TEFRA,” requires the Authority to
conduct a public hearing prior to the issuance of qualified 501(c)(3)
bonds. Pursuant to the Code, a notice must be published in one or more
newspapers at least 14 days prior to the date of the hearing.
The preparation of this “TEFRA notice” requires each borrower to
properly identify, by street address (or other description sufficient
under federal tax law), each project to be financed or refinanced with
bond proceeds. Under federal tax law, proceeds of the bonds may only
be expended for projects identified in the TEFRA notice.
Dormitory Authority Board Action
The Dormitory Authority may issue its bonds only upon receiving
authorization from its 11-member board. Generally, obtaining this
approval involves a two-step process. At the first board meeting, the
board adopts a resolution authorizing staff to proceed with the
transaction and engage the necessary professionals, such as bond
counsel, to prepare the financing documents. At the second meeting,
the board adopts the resolutions authorizing the issuance of the
bonds. These board meetings are held on a monthly basis.
The Authority may adopt the financing documents only if there has been
compliance with the requirements of SEQRA and TEFRA as discussed
above. In addition, because the State’s Public Authorities Control
Board (“PACB”) must approve all bonds issued by the Authority, the
Authority will not adopt any financing documents unless the approval
of PACB has been obtained. The PACB, which meets on a monthly basis,
is comprised of representatives of the Division of Budget, the State
Senate and the State Assembly.
In addition to the declaration of intent discussed above, the
Authority also requires that each borrower adopt its own board
resolution authorizing the borrowing of money from the Authority as a
condition to the Authority’s approval of the financing documents.
The financing documents approved by the Authority will include bond
resolutions authorizing the issuance of the bonds and the form of loan
agreement and other agreements to be entered into by the Authority and
the borrowers. The borrowers and their counsel will need to thoroughly
review drafts of the resolutions and loan agreement prior to action by
the Authority board.
Bond Sale and Closing
After a preliminary version of the Official Statement has been
distributed to potential investors, the Authority will sell the bonds
to the Underwriter for re-sale to investors. The loans to the
borrowers will be made with the proceeds from the sale of the bonds.
The bonds will be sold in accordance with a Bond Purchase Agreement,
in reliance upon a Letter of Representation from each borrower. The
Letter of Representation, in effect, is the borrower’s assurance that
the information contained in the Official Statement relative to the
borrower is accurate and complete. The Letter of Representation also
recites that the borrower will defend and indemnify the Authority and
the Underwriter from any losses sustained by them as a result of
claims based upon inaccurate or incomplete information provided by the
borrower.
The Authority will thereafter issue the bonds and the “closing” will
take place. At that time, the borrower will be required to sign and
deliver numerous documents, including the Loan Agreement, various
security documents and agreements requiring the borrower to comply
with disclosure obligations under federal securities laws as well as
requirements imposed by federal tax laws. Counsel to each borrower
will be required to deliver an opinion covering such things as
corporate existence and authorization, 501(c)(3) status,
enforceability of the financing documents, and compliance with
governmental requirements. As the financing progresses, the borrowers
and their counsel will be expected to thoroughly review drafts of
these documents and collaborate in their preparation.
Financial Covenants
It is expected that the Authority’s bonds will be secured by a
municipal bond insurance policy. As a condition to the issuance of its
insurance policy, the bond insurer may impose conditions on
participation (e.g., historical achievement of specified financial
benchmarks) as well as ongoing financial covenants. These covenants
may also restrict the ability of the borrower to issue debt in the
future unless certain financial tests are satisfied
Lock-Box and Revenue Pledge
Chapter 472 requires that each borrower establish an account with a
bank or trust company acceptable to the Authority into which the
borrower must deposit all amounts received from any school district,
social service district or any other payor on account of the
residential services provided by the borrower (“Lock Box Account”).
Each borrower is further required by Chapter 472 to grant the
Authority a security interest in the Account. It also provides that
the moneys on deposit in the Lock Box Account shall be subject to
withdrawal by the borrower only after payment of amounts then due to
the Authority. As a practical matter, the borrower will be able to
access funds in the Lock Box Account without action by the Authority
or another party, provided that it has paid the amounts due under the
Loan Agreement.
In addition, Chapter 472 provides that each borrower include in each
of its respective contracts with a social service district, school
district or any other payor, a provision requiring that the borrower
deposit all of its “maintenance rate payments" from such social
service district or school district or other payor into the Lock Box
Account. In the event of a failure by the applicable social services
district or school district to make a “maintenance rate payment” to
the borrower, the State Comptroller is required to withhold state
reimbursement to the applicable social services district or school
district in an amount equal to the unpaid obligation for the “capital
financing add on rate” and pay over such sum to the Authority or the
Bond Trustee upon certification of the Commissioner of the Office of
Children and Family Services or the State Education Department, as
applicable.
Loan Documentation, Prior Pledges and Payoff Letters
Borrowers and their counsel will need to carefully review any existing
loan documents for loans currently outstanding in order to ensure that
they obtain any required consents or waivers from their existing
lenders to borrow funds in this program. The borrowers and their
counsel will likewise be required to identify any prior pledges of the
borrowers’ revenues and provide a comprehensive list of existing
liens. Each borrower’s counsel will eventually need to provide
searches of county and state records, which will identify any
outstanding liens or restrictions.
Mortgage
Chapter 472 requires each borrower to grant to the Authority either a
mortgage on the real property used by the borrower to provide
residential services or such other interest in real property as is
acceptable to the Authority. In connection with the granting of a
mortgage to the Authority, a policy of title insurance and a current
survey of the mortgaged property may be required.
Costs of Issuance
There are various costs associated with the issuance of tax-exempt
bonds in general and an Authority bond issue in particular. These
costs include such items as Authority fees, Trustee fees, the
Underwriter’s discount, a bond insurance premium, bond issuance fees,
rating agency fees, Bond Counsel fees, and printing and publication
costs. If a series of bonds is issued for the benefit of more than one
borrower, these costs will be allocated among the borrowers on a
pro-rata or other equitable basis. Each borrower will be required to
pay or finance its own costs of obtaining title insurance and surveys
in connection with the granting of its mortgage and to pay the fees of
its counsel and financial advisor (if any).
Most if not all of the costs of issuance described above may be
financed with bond proceeds. However, where the bonds to be issued are
“qualified 501(c)(3) bonds,” the Internal Revenue Code prohibits the
financing of costs of issuance in excess of two percent of the
proceeds of tax-exempt bonds. Therefore, to the extent that the costs
of issuance exceed this limit, the borrowers will need to arrange for
their payment from their own funds or from the proceeds of taxable
bonds.
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
VENDOR RESPONSIBILITY QUESTIONNAIRE
COMPLETED BY THE VENDOR
Vendor Responsibility Summary
Procurement laws and guidelines require the award of State contracts
to responsible vendors. Vendor responsibility generally means that a
vendor has the integrity to justify the award of public dollars and
the capacity to fully perform the requirements of the contract. It is
the State Agency’s responsibility to evaluate the responsibility of a
prospective contractor/vendor. A responsibility determination, wherein
the State determines that it has reasonable assurances that a
contractor/vendor is responsible, is an important part of the
procurement process, promoting fairness in contracting and protecting
a contracting Agency and the State against failed contracts.
Notes:
*
This Questionnaire is being required by OCFS for purposes of
supporting an agency’s application for capital project financing
of a congregate care facility for which OCFS establishes a State
aide maintenance rate pursuant to Section 398-a of Social Services
Law and Section 4405 of Education Law.
*
An applicant agency must submitted a completed and signed Vendor
Questionnaire as part of its initial application for capital
financing.
*
Where the applicant agency is now completing the comprehensive
application, the agency will only be required to submit an
entirely new Vendor Questionnaire where circumstances have
changed. Where circumstances have not changed, the applicant
agency may attach a signed and notarized Affidavit of No Change
Form (attached) along with the most recent copy of its previously
submitted Vendor Questionnaire.
*
All references in this Questionnaire to “contract agency” or
“contractor” should be interpreted to mean the voluntary agency
submitting an application for capital financing, either through
the Dormitory Authority of the State of New York or through a
waiver of the property parameter of the applicant agency’s Maximum
State Aid Rate.
The following factors are considered in making a responsibility
determination:
*
Legal Authority to do business in New York State
*
Integrity
*
Capacity – both organization and financial
*
Previous performance
A contracting Agency is required to conduct a review of a prospective
contractor to provide reasonable assurances that the vendor is
responsible. This Questionnaire is designed to provide information to
assist a contracting Agency in assessing a vendor’s responsibility
prior to entering into a contract with the vendor.
Prospective contractors must answer every question contained in this
Questionnaire. Each “Yes” response requires additional information.
The vendor must attach a written response that adequately details each
affirmative response. The completed Questionnaire and attached
responses will become part of the procurement record. Please number
each response to match the Questionnaire.
It is imperative that the person completing the Vendor Responsibility
Questionnaire be knowledgeable about the proposing contractor’s
business and operations as the Questionnaire information must be
attested to by an owner or officer of the vendor. Please read the
certification requirement at the end of this Questionnaire carefully.
The certification must be notarized.
1. VENDOR IS:
PRIME CONTRACTOR SUB-CONTRACTOR
2. VENDOR’S LEGAL BUSINESS NAME
 
3. IDENTIFICATION NUMBERS
a) FEDERAL EMPLOYER ID #  
b) FEDERAL DUNS #  
4. D/B/A – Doing Business As (if applicable) & COUNTY FILED:
 
 
5. WEBSITE ADDRESS (if applicable)
 
6. ADDRESS OF PRIMARY PLACE OF BUSINESS/EXECUTIVE OFFICE
 
7. TELEPHONE NUMBER
 
8. FAX NUMBER
 
9. ADDRESS OF PRIMARY PLACE OF BUSINESS/EXECUTIVE OFFICE IN NEW YORK
STATE, if different from above
 
10. TELEPHONE NUMBER
 
11. FAX NUMBER
 
12. PRIMARY PLACE OF BUSINESS IN NEW YORK STATE IS:
Owned Rented
If rented, please provide landlord’s name, address, and telephone
number below:
 
13. AUTHORIZED CONTACT FOR THIS QUESTIONNAIRE
Name  
Title  
Telephone Number  
Fax Number  
e-mail  
14. VENDOR’S BUSINESS ENTITY IS (please check appropriate box and
provide additional information):
a) Business Corporation
Date of Incorporation  
State of Incorporation*  
b) Sole Proprietor
Date Established  
c) General Partnership
Date Established  
d) Not-for-Profit Corporation
Date of Incorporation  
State of Incorporation*  
Charities Registration Number  
To verify number click on link
http://fairchild.oag.state.ny.us/online_forms/search_charities.jsp
e) Limited Liability Company (LLC)
Date Established  
f) Limited Liability Partnership
Date Established  
g) Other – Specify:  
Date Established  
Jurisdiction Filed (if applicable)  
* If not incorporated in New York State, please provide a copy of
authorization to do business in New York.
15. PRIMARY BUSINESS ACTIVITY - (Please identify the primary business
categories, products or services provided by your business)
 
16. NAME OF WORKERS’ COMPENSATION INSURANCE CARRIER:  
17. LIST ALL OF THE VENDOR’S PRINCIPAL OWNERS AND THE THREE OFFICERS
WHO DIRECT THE DAILY OPERATIONS OF THE VENDOR (Attach additional pages
if necessary):
a) NAME (print)
 
TITLE
 
b) NAME (print)
 
TITLE
 
c) NAME (print)
 
TITLE
 
d) NAME (print)
 
TITLE
 
18.
Is the vendor certified in New York State as a (check please):
Minority Business enterprise (MBE)
Women’s Business Enterprise (WBE)
Disadvantaged Business Enterprise (DBE)?
Please provide a copy of any of the above certifications that apply.
Yes No
19.
Does the vendor use, or has it used in the past ten (10) years, any
other Business Name, FEIN, or D/B/A other than those listed in items
2-4 above?
List all other business name(s), Federal employer Identification
Number(s) or any D/B/A names and the dates that these names or numbers
were/are in use. Explain the relationship to the vendor.
Yes No
20.
Are there any individuals now serving in a managerial or consulting
capacity to the vendor, including principal owners and officers, who
now serve or in the past three (3) years have served as:
a.
An elected or appointed public official or officers?
List each individual’s name, business title, the name of the
organization and position elected or appointed to, and dates of
service.
b.
A full or part-time employee in a New York State agency or as a
consultant, in their individual capacity, to any New York State
agency?
List each individual’s name business title or consulting capacity and
the New York State agency name, and employment position with
applicable service dates.
c.
If yes to item #20b, did this individual perform services related
to the solicitation, negotiation, operation and/or administration
of public contracts for the contracting agency?
List each individual’s name, business title or consulting capacity and
the New York State agency name, and consulting/advisory position with
applicable service dates. List each contract name and assigned NYS
number.
d.
An officer of any political party organization in New York State,
whether paid or unpaid?
List each individual’s name, business title or consulting capacity and
the official political party position held with applicable service
dates.
Yes No
Yes No
Yes No
Yes No
21.
Within the past five (5) years, has the vendor, any individuals
serving in managerial or consulting capacity, principal owners,
officers, major stockholder(s) (10% or more of the voting shares for
publicly traded companies, 25% or more of the shares for all other
companies), affiliate1 or any person involved in the bidding or
contracting process:
a.
1. been suspended, debarred or terminated by a local, state or
federal authority in connection
with a contract or contracting process;
2.
been disqualified for cause as a bidder or any permit, license,
concession franchise or lease;
3.
entered into an agreement to a voluntary exclusion from
bidding/contracting;
4.
had a bid rejected on a New York State contract for failure to
comply with the MacBride Fair Employment Principles;
5.
had a bid rejected on a local, state or federal contract for
failure to meet statutory affirmative action or M/WBE requirements
on a previously held contract;
6.
had status as a Women’s Business Enterprise, Minority Business
enterprise or Disadvantaged Business Enterprise denied,
de-certified, revoked or forfeited;
7.
been subject to an administrative proceeding or civil action
seeking specific performance or restitution in connection with any
local, state or federal government contract;
8.
been denied an award of a local, state or federal government
contract, had a contract suspended or had a contract terminated
for non-responsibility;
9.
had a local, state or federal government contract suspended or
terminated for cause prior to the completion of the term of the
contract; or
10.
had a license to provide services revoked or suspended?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Question 21 Continued
b.
been indicted, convicted, received a judgment against them or a
grant of immunity for any business-related conduct constituting a
crime under local, state or federal law including but not limited
to, fraud, extortion, bribery, racketeering, price-fixing, bid
collusion or any crime related to truthfulness and/or business
conduct?
Yes No
b.
been issued a citation, notice, violation order, or are pending an
administrative hearing or proceeding or determination for
violations of:
1.
federal, state or local health laws, rules or regulations,
including but not limited to Occupational Safety & Health
Administration (OSHA) or New York State labor law;
2.
state or federal environmental laws;
3.
unemployment insurance or workers’ compensation coverage or claim
requirements;
4.
Employee Retirement Income Security Act (ERISA);
5.
federal, state or local human rights laws;
6.
civil rights laws;
7.
federal or state security laws;
8.
federal Immigration and Naturalization Services (INS) and Alienage
laws;
9.
state or federal anti-trust laws; or
10.
charity or consumer laws?
For any of the above, detail the situation(s), the date(s), the
name(s), title(s), address(es) of any individuals involved and, if
applicable, any contracting agency, specific details related to the
situation(s) and any corrective action(s) taken by the vendor.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
b.
been issued a citation, notice, violation order, or are pending an
administrative hearing or proceeding or determination for
violations of:
11.
federal, state or local health laws, rules or regulations,
including but not limited to Occupational Safety & Health
Administration (OSHA) or New York State labor law;
12.
state or federal environmental laws;
13.
unemployment insurance or workers’ compensation coverage or claim
requirements;
14.
Employee Retirement Income Security Act (ERISA);
15.
federal, state or local human rights laws;
16.
civil rights laws;
17.
federal or state security laws;
18.
federal Immigration and Naturalization Services (INS) and Alienage
laws;
19.
state or federal anti-trust laws; or
20.
charity or consumer laws?
For any of the above, detail the situation(s), the date(s), the
name(s), title(s), address(es) of any individuals involved and, if
applicable, any contracting agency, specific details related to the
situation(s) and any corrective action(s) taken by the vendor.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
b.
been issued a citation, notice, violation order, or are pending an
administrative hearing or proceeding or determination for
violations of:
21.
federal, state or local health laws, rules or regulations,
including but not limited to Occupational Safety & Health
Administration (OSHA) or New York State labor law;
22.
state or federal environmental laws;
23.
unemployment insurance or workers’ compensation coverage or claim
requirements;
24.
Employee Retirement Income Security Act (ERISA);
25.
federal, state or local human rights laws;
26.
civil rights laws;
27.
federal or state security laws;
28.
federal Immigration and Naturalization Services (INS) and Alienage
laws;
29.
state or federal anti-trust laws; or
30.
charity or consumer laws?
For any of the above, detail the situation(s), the date(s), the
name(s), title(s), address(es) of any individuals involved and, if
applicable, any contracting agency, specific details related to the
situation(s) and any corrective action(s) taken by the vendor.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
22.
In the past three (3) years, has the vendor or its affiliates1 had any
claims, judgments, injunctions, liens, fines or penalties secured by
any governmental agency?
Indicate if this is applicable to the submitting vendor or affiliate.
State whether the situation(s) was a claim, judgment, injunction, lien
or other with an explanation. Provide the name(s) and address(es) of
the agency, the amount of the original obligation and outstanding
balance. If any of these items are open, unsatisfied, indicate the
status of each item as “open” or “unsatisfied.”
Yes No
23.
Has the vendor (for profit and not-for profit corporations) or its
affiliates1, in the past three (3) years, had any governmental audits
that revealed material weaknesses in its system of internal controls,
compliance with contractual agreements and/or laws and regulations or
any material disallowances?
Indicate if this is applicable to the submitting vendor or affiliate.
Detail the type of material weakness found or the situation(s) that
gave rise to the disallowance, any corrective action taken by the
vendor and the name of the auditing agency.
Yes No
24.
Is the vendor exempt from income taxes under the Internal Revenue
Code?
Indicate the reason for the exemption and provide a copy of any
supporting information.
Yes No
25.
During the past three (3) years, has the vendor failed to:
a.
file returns or pay any applicable federal, state or city taxes?
Identify the taxing jurisdiction, type of tax, liability year(s), and
tax liability amount the vendor failed to file/pay and the current
status of the liability.
b.
file returns or pay New York State unemployment insurance?
Indicate the years the vendor failed to file/pay the insurance and the
current status of the liability.
Yes No
Yes No
26.
Have any bankruptcy proceedings been initiated by or against the
vendor or its affiliates1 within the past seven (7) years (whether or
not closed) or is any bankruptcy proceeding pending by or against the
vendor or its affiliates regardless of the date of filing?
Indicate if this is applicable to the submitting vendor or affiliate.
If it is an affiliate, include the affiliate’s name and FEIN. Provide
the court name, address and docket number. Indicate if the proceedings
have been initiated, remain pending or have been closed. If closed,
provide the date closed.
Yes No
27.
Is the vendor currently insolvent, or does vendor currently have
reason to believe that an involuntary bankruptcy proceeding may be
brought against it?
Provide financial information to support the vendor’s current
position, for example, Current Ratio, Debt Ratio, Age of Accounts
Payable, Cash Flow and any documents that will provide the agency with
an understanding of the vendor’s situation.
Yes No
28.
In the past five (5) years, has the vendor or any affiliates1:
a.
defaulted or been terminated on, or had its surety called upon to
complete, any contract (public or private) awarded;
b.
received an overall unsatisfactory performance assessment from any
government agency on any contract; or
c.
had any liens or claims over $25,000 filed against the firm which
remain undischarged or were unsatisfied for more than 90 days?
Indicate if this is applicable to the submitting vendor or affiliate.
Detail the situation(s) that gave rise to the negative action, any
corrective action taken by the vendor and the name of the contracting
agency.
Yes No
Yes No
Yes No
29.
Has the vendor been a contractor or subcontractor on any contract with
any Government agency in the past five (5) years?
List the agency name, contract effective dates, contract amount,
contract number and Government contact information on the attached
contract List.
Yes No
Public Agency Contracts Lists
For all contracts and subcontracts with any Government Agency during
the last 5 years, please provide the information requested below.
(Photocopy and attach additional pages as necessary)
Public Agency Name:
Contract Number:
Contract Amount:
Program Name:
Contract Term:
Government Contact Person:
Telephone Number:
Email Address:
Public Agency Name:
Contract Number:
Contract Amount:
Program Name:
Contract Term:
Government Contact Person:
Telephone Number:
Email Address:
Public Agency Name:
Contract Number:
Contract Amount:
Program Name:
Contract Term:
Government Contact Person:
Telephone Number:
Email Address:
Public Agency Name:
Contract Number:
Contract Amount:
Program Name:
Contract Term:
Government Contact Person:
Telephone Number:
Email Address:
Public Agency Name:
Contract Number:
Contract Amount:
Program Name:
Contract Term:
Government Contact Person:
Telephone Number:
Email Address:
CERTIFICATION:
The undersigned recognizes that this questionnaire is submitted for
the express purpose of assisting the State of New York or its agencies
or political subdivisions in making a determination regarding an
applicant agency’s application for capital project financing of a
congregate care program, an award of contract or approval of a
subcontract; acknowledges that the State or its agencies and political
subdivisions may in its discretion, by means which it may choose,
verify the truth and accuracy of all statements made herein;
acknowledges that intentional submission of false or misleading
information may constitute a felony under Penal Law Section 210.40 or
a misdemeanor under Penal Law Section 210.35 or Section 210.45, and
may also be punishable by a fine and/or imprisonment of up to five
years under 18 USC Section 1001 and may result in contract termination;
and states that the information submitted in this questionnaire and
any attached pages is true, accurate and complete.
The undersigned certifies that he/she:
*
Has not altered the content of the questions in the Questionnaire
in any manner;
*
Has read and understands all of the items contained in the
Questionnaire and any pages attached by the submitting vendor;
*
Has supplied full and complete responses to each item therein to
the best of his/her knowledge, information and belief;
*
Is knowledgeable about the submitting vendor’s business and
operations;
*
Understands that New York State will rely on the information
supplied in this Questionnaire when responding to the agency’s
request for funding; and
*
Is under a duty to notify the procuring State Agency of any
material changes to the vendor’s responses herein prior to the
State’s response to the agency’s funding request.
Applicant Agency:
_______________________________________________________________________________________
(Legally Incorporated Name)
__________________________________________
_______________________________________ ____________
(Signature) (Title) (Date)
NOTARIZATION:
STATE OF NEW YORK
COUNTY OF ( ) SS.:
On this __________ day of ____________________, 20_____, before me
personally came _______________________
__________________________________________ to me known, who being
sworn did depose and say that he/she
resides in __________________________________________________; that
he/she is the _____________________
_______________________________________ of
_____________________________________________________
Corporation described herein and which executed the above instrument;
and that he/she signed his/her name thereto by like order of the Board
of Directors of said Corporation.
______________________________________________________ My Commission
Expires ___________________
(Notary Public) (Date)
AFFIDAVIT OF NO CHANGE
VOLUNTARY AGENCY:
_________________________________________________________________
The undersigned, being duly sworn, deposes and says:
1. I am an officer of
___________________________________________________________
(hereinafter the “Agency”), which is currently requesting OCFS
approval of Capital Project financing of a congregate care facility
operated by said Agency.
2.
The Agency previously submitted a Vendor Questionnaire prior to
the date hereof to
_____________________________________________________________________________________
in connection with an initial application to OCFS for capital project
financing of a congregate care facility.
3. Attached is an accurate and true copy of such previously submitted
Vendor Questionnaire.
4. I hereby certify that there has been no material change in any of
the information pertaining to the Vendor Questionnaire:
__________________________________________
NAME
__________________________________________
TITLE
Sworn before me this
_________________ day of ______________________,
________________________
__________________________________________
Notary Public
1
1
1
1
1 "Affiliate" meaning: (a) any entity in which the vendor owns more
than 50% of the voting stock; (b) any individual, entity or group of
principal owners or officers who own more than 50% of the voting stock
of the vendor; or (c) any entity whose voting stock is more than 50%
owned by the same individual, entity or group described in clause (b).
In addition, if a vendor owns less than 50% of the voting stock of
another entity, but directs or has the right to direct such entity's
daily operations, that entity will be an "affiliate" for purposes of
this questionnaire.
Page 36 of 36
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