State of Connecticut Office of Policy and Management

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PERSONAL SERVICE AGREEMENTS (PSA); PURCHASE OF SERVICE (POS)
Ethics Affidavits & Certifications for State Contracts

Forms & Descriptions   Summary Chart   Definitions   Other Notes

The Office of Policy and Management created the ethics forms (below) to assist executive branch agencies in complying with the State of Connecticut's current contracting requirements, pursuant to the Connecticut General Statutes and Executive Orders.

Note that these forms may be submitted as an original hard copy or an electronic pdf. 

Form 1. Gift and Campaign Contribution Certification
This certification accompanies a State contract, as defined in Governor Dannel P. Malloy's Executive Order No. 49, with a value of $50,000 or more in a calendar or fiscal year.  The completed form is submitted by the contractor to the awarding State agency at the time of contract execution.  The form is also used when an updated certification is needed due to a change in the information contained in the most recently filed certification, for new bids or proposals for a contract, and for updates required at the 12 month anniversary of the most recently filed certification.

Form 2.Rescinded on 01-Aug-07.  Use Form 1.

Form 3. Certification of State Agency Official or Employee Authorized to Execute Contract   
Rev.5/26/15   Adobe icon        Form 3 - PDF fillable    Word icon  Form 3 - Word fillable format

This certification accompanies a State contract, as defined in Governor Dannel P. Malloy's Executive Order No. 49, with a value of $50,000 or more in a calendar or fiscal year.  The completed form is signed at the time of contract execution by the State agency official or employee authorized to execute the contract on behalf of the awarding State agency.

Form 4.Rescinded on 01-Aug-07.  Use Form 1.

Form 5. Consulting Agreement Affidavit   
Rev. 3/28/14    Adobe icon   Adobe.pdf       Word icon  Word.doc

This affidavit accompanies a bid or proposal for the purchase of goods or services with a value of $50,000 or more in a calendar or fiscal year.  Form 5 is normally submitted by the contractor to the awarding State agency with the bid or proposal, however, for a sole source or no bid contract, it is submitted at the time of contract execution.

Form 6. Affirmation of Receipt of State Ethics Laws Summary
Rev. 10/01/11   Adobe icon   Adobe.pdf    Word icon  Word.doc
This affirmation accompanies a large State construction contract or a large State procurement contract with a cost of more than $500,000.  Form 6 is normally submitted by the contractor to the awarding State agency with the bid or proposal.  However, for a sole source or no bid contract, Form 6 is submitted at the time of contract execution.
When applicable, Form 6 is also used by a subcontractor or consultant of the contractor.  The subcontractor or consultant submits the form to the contractor, who then submits it to the awarding State agency.

Forms 6A, 6B, 6C.  Rescinded on 01-Aug-07.  Use Form 6.

Form 7.  Iran Certification

Rev. 3/28/14    Adobe icon  Adobe.pdf    Word iconWord.doc

Effective October 1, 2013, this form must be submitted for any large state contract, as defined in section 4-250 of the Connecticut General Statutes.  This form must always be submitted with the bid or proposal, or if there was no bid process, with the resulting contract, regardless of where the principal place of business is located.  Entities whose principal place of business is located outside of the United States are required to complete the entire form, including the certification portion of the form.  United States subsidiaries of foreign corporations are exempt from having to complete the certification portion of the form.  Those entities whose principal place of business is located inside of the United States must also fill out the form, but do not have to complete the certification portion of the form.

Back To TopSUMMARY CHART
The chart belows summarizes who signs which ethics form, and when each form is submitted during the contracting process.

WHEN TO SUBMIT

ETHICS FORMS

Signed by

AGENCY

ALL Contracts

value

$50 K or

more

Signed by CONTRACTOR

ALL Contracts

value

$50 K or

more

LARGE Contracts

cost or value

$500 K or

more

submit form

with

bid or proposal

Form 5**

Form 6***

Form 7

submit form

at time of

contract execution

Form 3

Form 1

Form 5**

Form 6***

Form 7

submit form

after

contract execution

Form 6***

submit updated form

not later than 14 days

after the 12

month anniversary of the most recently filed certification or updated certification

Form 1

submit updated form

due to change in information

not later than 30 days after the effective date

of such change

Form 1

Form 5**

Form 6***

submit updated form with any new bid or proposal

Form 3

Form 1

submit new form with contract amendment

Form 3

Form 7

**   Form 5 is normally submitted by the contractor to the awarding State agency with the bid or proposal.  However, for a sole source or no bid contract, it is submitted at the time of contract execution.

*** Form 6 is normally submitted by the contractor to the awarding State agency with the bid or proposal.  However, for a sole source or no bid contract, Form 6 is submitted at the time of contract execution.  When applicable, Form 6 is also used by a subcontractor or consultant of the contractor.  The subcontractor or consultant submits the form to the contractor, who then submits it to the awarding State agency.  Depending on when the contractor engages the subcontractor or consultant, the contractor either submits the form at the time of contract execution or after contract execution.

  • Cost of the contract means the dollar amount (or equivalent benefit) expended by the State in accordance with the contract.
Example:
OPM entered into a contract with Servus Management Corporation to manage the State office complex located at 410-474 Capitol Avenue in Hartford.  OPM pays the contractor a specified amount of money for this service.  This contract represents a cost expended by the State.
  • Value of the contract means the dollar amount (or equivalent benefit) expended or received by the State in accordance with the contract.
Example:
OPM entered into an agreement with Pinpoint Power whereby, in the event of a power shortage, certain State agencies may be asked to use their own emergency generators.  In exchange, the contractor pays the State a specified amount of money to compensate for the service interruption.  This contract represents a value received by the State.
  • Large state construction contract or large procurement contract as defined in Connecticut General Statutes § 1-101mm(3) means any contract, having a cost of more than $500,000 for (A) the remodeling, alteration, repair or enlargement of any real asset, (B) the construction, alteration, reconstruction, improvement, relocation, widening or changing of the grade of a section of a state highway or a bridge, (C) the purchase or lease of supplies, materials or equipment, as defined in section 4a-50, or (D) the construction, reconstruction, alteration, remodeling, repair or demolition of any public building.
Back To TopOTHER NOTES

Affidavits and certifications are NOT required for grants or loans, as such awards are not:

  1. large state contracts, as defined by Connecticut General Statutes
    § 4-250;
  2. State Contracts, as defined by Executive Order 49; or
  3. contracts for the purchase of goods and services, as used in Connecticut General Statutes § 4a-81.
Affidavits are not required for contracts between a state agency or a quasi-public state agency and a political subdivision of the State.

For Further Information, Contact:
Please direct any questions about the ethics forms to