Contract & Grant Disclosure Form

Description

CONTRACT AND GRANT DISCLOSURE AND CERTIFICATION FORM F-1 Failure to complete all the following information may result in a delay in obtaining a contract, lease, purchase agreement, or grant award with any Arkansas State Agency. SUBCONTRACTOR: SUBCONTRACTOR NAME: Contractor for which this is a subcontractor: YES NO Estimated dollar amount of subcontract: IS THIS FOR: TAXPAYER ID NAME: YOUR LAST NAME: FIRST NAME: Goods? Services Both? MI: ADDRESS: CITY: STATE: ZIP CODE: COUNTRY: UNITED STATES OF AMERICA AS A CONDITION OF OBTAINING, EXTENDING, AMENDING, OR RENEWING A CONTRACT, LEASE, PURCHASE AGREEMENT, OR GRANT AWARD WITH ANY ARKANSAS STATE AGENCY, THE FOLLOWING INFORMATION MUST BE DISCLOSED: FO R I N D I V I D U A L S * Indicate below if: you, your spouse or the brother, sister, parent, or child of you or your spouse is a current or former: Member of the General Assembly, Constitutional Officer, State Board or Commission Member, or State Employee: Position Held Mark (ü) Current Former Name of Position of Job Held [senator, representative, name of board/commission, data entry, etc.] General Assembly What is the person(s) name and how are they related to you? For How Long? (i.e., Jane Q. Public, spouse, John Q. Public, Jr., child, etc.) From MM/YY To MM/YY Person's name(s) Relation Constitutional Officer State Board or Commission Member State Employee None of the above applies F O R A N VEE NNDTOI TR Y ( B U S I N E S S ) * Indicate below if any of the following persons, current or former, hold any position of control or hold any ownership interest of 10% or greater in the entity: member of the General Assembly, Constitutional Officer, State Board or Commission Member, or State Employee, or the spouse, brother, sister, parent, or child of a member of the General Assembly, Constitutional Officer, State Board or commission Member, or State Employee. Position of control means the power to direct the purchasing policies or influence the management of the entity. What is the person(s) name and what is his/her % of ownership interest and/or Mark (ü) For How Long? Name of Position of Job Held what is his/her position of control? Position Held (senator, representative, name of Position of Ownership From To board/commission, data entry, etc.