Request for Proposal - Ottawa County

Attacnment IwOHIo DEPARTMENTOF PUBLIC SAFETYOHIO DEPARTMENT OF PUBLIC SAFETYDIVISION OF HOMELAND SECURITYhttp Jiwww.homelandsecurity.ohio.govGOVERNMENT BUSINESS AND FUNDlNG CONTRACTSIn accordance wilh section 2909.33 of the Ohio Revised CodeDECLARATION REGARDING MATERIAL ASSISTANCE/NONASSISTANCE TO A TERRORIST ORGANIZATIONThis form serves as a declaralion by an applicanl for a govemment contract or fundang of material assislance/nonassistance to an organizaiion on the LJ.S.Department of Stale Te(orist Exclusion List (TEL"). Please see the Ohio Homeland Security Division Web site for a copy of the TEL.Any answer of yes" lo any question, or the failure to answer "no" to any question on this dedaration shall serve as a disclosure that material assistance to anorganization identiiied on the U.S. Department of State lerrorist Exclusion List has been provided. Failure to disclose the provision of material assistance tosuch an organization or knowingly making false stalemenls regarding material assistiance to such an organizatjon is a felony ol the fifth degreeFor the purposes of this declaration, "material supporl or resources" means currency, palmenl instruments, other financial securities, funds, transfer of funds,financial services, communicalions, lodging, kaining, safe houses, false documentation or identification. communications equipment, facilities, weapons, lethalsubstances, explosives, personnel, transportation, and other physical assets, except medicine or religiols materials.COMPLETE THIS SECTION ONLY IF YOU ARE AN INDEPENDENT CONTRACTORLAST NAMETHO[4E ADDRESSICITY STATE ztP COUNTYHOME PHONEWORK PHONECOMPLETE THIS SECTION ONLY IF YOU ARE A COMPANY, BUSINESS OR ORGANIZATIONBUSINESS/ORGANIZAIION NAMEPHONEBUSINESS ADDRESSctw zlP COUNTYBUSINESS/ORGANIZATION REPRESENTATIVE NAME TITLEDECLARATIONIn accordance with section 2909,32 (AX2)(b) of the Ohio Revised CodeFor each question, indicate eithe. "yes," or "no" in the space provided. Responses must be truthtul to the best of your knowledge.'1. Are you a member of an organization on lhe U.S. Department of State Terrorist Exclusion Ust?2. Have you used any position ot prorninence you have with any country to persuade others to support an organization on the U.S.Department of State Tenodst Exclusion List?3. Have you knowingly solicited funds o. other things of value for an organization on the U.S. Department of State Terro.ist ExclusionList?4. Have you solicited any individual for membership an an organization on the U.S. Deparbnent of State Terrorist Exclusion List?5. Have you committed an act that you know, or reasonably should have known, affords 'material suooort or resources'to anorganization on the U.S. Departrnent of State Terrorist Exctus,on List?6. Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department of State TenorislExclusion List, or a person you knew to be engaged in planning. assisting, or carrying out an act of terro sm?I v"" !ruon v"" n r.ro! v"" I r'roI vu" I r.ron v"t f] r'rolvo [ruolf an applicant is prohibited from receiving a govemment contract or funding due to a positive indacation on this form, the applicant may request the OhioDepartment of Public Safely to review the prohibition. Please see the Ohio Homeland Security Web site for information on how to file a requeit for review.CERTIFICATIONI hereby certify lhat the answers I have made to all of the questions on this declaration are kue lo the best of my knowledge. I understand that if thisdeclaration is not completed in jts entirety, it will not be processed and I will be automalically disquatified. I understand th-at I am responsible for thecorrectness of this declaration. I understand thal failure to disclose the provision of materiat assistance to an organization identified on the U.S.Department of State Terrorist Exclusion List, or knowingly making false statements regarding malerial assistance to-srJch an organization is a feionyof the fifth degree. I understand lhal any answer of "yes'to any question, or lhe fallure to answer "no" to any question on this d;claration sha serv;as a disclosure that material assislance lo an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided bymyself or my otganization. lf I am signing this on behalf of a company, business or organization, I hereby acknowledge that I have the authority t6make this certification on behalf of the company, busaness or organization referenced above on of this declaration.XTEHLS 0038 211 Page 2 ol2