For the purposes of this Section:
CalPERS Contract-Related Disclosure Form | |
(To be used if Contractor is not required to file a Placement Agent Information Disclosure Form (2 CCR § 559)) | |
This form is to be used for all Contract-Related Disclosures, including Proposals. | |
Please refer to title 2 California Code Regulations section 559.1(b)(1) through (b)(3), prior to completing this form. | |
a. Solicitation or Contract Number: | |
___________________________ | |
b. Proposer or Contractor Name: | |
___________________________ | |
c. Name of Individual Authorized to bind the Proposer or Contractor: | |
___________________________ | |
d. Contact Person (if different than above): | |
___________________________ | |
e. E-mail Address: | |
___________________________ | |
f. Phone No: | |
___________________________ | |
g. Name of CalPERS Contact (if applicable): | |
___________________________ | |
Have you, your firm or your firm's principals, employees, agents, or affiliates compensated or agreed to compensate, directly or indirectly, any Agent as defined in section 559.1(a)(1) (whether or not employed by you) or any entity to act as Agent in connection with this Solicitation or Contract? (§ 559.1(b)(1)) | |
[] Yes. [] No. | |
If you checked Yes, please respond to questions 1 through 5 below, and sign and date the Form on the final page. | |
If you checked No, please respond to question 5 below, and sign and date this Form on the final page. |
1. Please list the names and relationships for each Agent in connection with the CalPERS Solicitation or Contract, including a description of the relationship with the Proposer or Contractor. (Add an additional page if necessary.) Please check the box to the left if the Agent is a current or former CalPERS Board Member, Staff Member, consultant, or has a Familial Relationship with any such individual. | ||
Name | Relationship | |
[] | ||
[] | ||
[] | ||
[] | ||
[] | ||
2. Please attach a copy of all contracts, agreements, or other documents memorializing the relationship between the Proposer or Contractor and the Agent. When an entity is retained as an Agent, please also include the requested information for any officer, director, or employee actively providing Agent services with regard to CalPERS or receiving more than 15% of the Agent fees. | ||
________ | ||
3. Provide a description of any financial or Familial Relationship(s) between the Agent and a Board Member or Staff Member, including the names of the Board Member(s) and/or Staff Members: | ||
________ | ||
4. Describe any Things of Value given or offered by the Agent to a Board Member or Staff Member during the twelve (12) months preceding the date the Contract-Related Disclosure Form is due. | ||
________ | ||
5. Describe any Things of Value given or offered by the Proposer or Contractor to a Board Member or Staff Member during the twelve (12) months preceding the date the Contract-Related Disclosure Form is due. | ||
________ | ||
By executing this form the undersigned represents and warrants the information set forth herein is true and correct. The undersigned agrees to update this information within 14 calendar days of the date Proposer or Contractor knows or reasonably should have known of any defect or changes to this information. | ||
The Contract-Related Disclosure Form and attachments shall be a public record subject to disclosure under the California Public Records Act. No confidentiality restrictions shall be placed on information submitted by the Proposer or Contractor. | ||
The undersigned represents and agrees it shall make a representation and warranty as to the continuing accuracy of this information in any final written agreement between it and CalPERS. | ||
I, the official named below, acknowledge and declare I have read and understand CCR section 559.1, and that the above-named firm has provided information required by section 559.1 and this Form. I am duly authorized to make this declaration on behalf of the above-named firm, and declare the foregoing is true and correct as of the date of execution of this document. I further acknowledge my firm's responsibility to provide updates in the event this information is determined to be incorrect or has changed. |
___________________________ | ___________________________ | |||
Authorized Signature | Date | |||
___________________________ | ||||
Name and Title | ||||
Form #PERS01A0068 |
Cal. Code Regs. Tit. 2, § 559.1
Note: Authority cited: Government Code sections 20120 and 20121. Reference: Government Code sections 20151, 20152.5, 20153, 87100 and 87103.