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Connecticut Affidavit by Entity Form

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Connecticut Affidavit by Entity Form
Connecticut Affidavit by Entity Form
Form C
07-08-2009
STATE%OF%CONNECTICUT%
NONDISCRIMINATION%CERTIFICATION%—%Affidavit%
By%Entity%
For%Contracts%Valued%at%$50,000%or%More
Documentation in the form of an affidavit signed under penalty of false statement by a chief executive
officer, president, chairperson, member, or other corporate officer duly authorized to adopt corporate,
company, or partnership policy that certifies the contractor complies with the nondiscrimination
agreements and warranties under Connecticut General Statutes §§ 4a-60(a)(1) and 4a-60a(a)(1), as
amended
INSTRUCTIONS:
For use by an entity (corporation, limited liability company, or partnership) when entering into any contract
type with the State of Connecticut valued at $50,000 or more for any year of the contract. Complete all
sections of the form. Sign form in the presence of a Commissioner of Superior Court or Notary Public.
Submit to the awarding State agency prior to contract execution.
AFFIDAVIT:
I, the undersigned, am over the age of eighteen (18) and understand and appreciate the obligations of
an oath. I am _________________________ of ________________________________ , an entity
Signatory’s Title Name of Entity
duly formed and existing under the laws of _____________________________________.
Name of State or Commonwealth
I certify that I am authorized to execute and deliver this affidavit on behalf of
________________________________ and that ________________________________
Name of Entity Name of Entity
has a policy in place that complies with the nondiscrimination agreements and warranties of Connecticut
General Statutes §§ 4a-60(a)(1)and 4a-60a(a)(1), as amended.
___________________________________________
Authorized Signatory
___________________________________________
Printed Name
Sworn and subscribed to before me on this ______ day of ____________, 20____.
___________________________________________ ___________________________________
Commissioner of the Superior Court/ Commission Expiration Date
Notary Public
Connecticut Affidavit by Entity Form