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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 partnershippolicy that certifies the contractor complies with the nondiscrimination
agreements and warranties under Connecticut General Statutes §§ 4a-60(a)(1)and4a-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 Connecticutvalued 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 formedand 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 EntityName of Entity
has a policy in place that complies with the nondiscrimination agreements and warranties ofConnecticut