State of Connecticut Office of Policy and Management

PERSONAL SERVICE AGREEMENTS (PSA); PURCHASE OF SERVICE (POS)
Ethics Affidavits & Certifications for State Contracts Forms & Descriptions   Definitions 
The Office of Policy and Management created the ethics forms (below) to assist executive branch agencies in complying with the State of Connecticut's current contracting requirements, pursuant to the Connecticut General Statutes and Executive Orders. Note that these forms may be submitted as an original hard copy or an electronic pdf. 
Form 1. Campaign Contribution Certification 
This certification is defined in Public Act No. 21-76, for contracts with a value of $50,000 or more in a calendar year or fiscal year. The completed form is submitted by a non-state entity EITHER as an appendix to a bid or proposal for a state contract OR, in the case of a non-competitive contract, prior to contract execution. If there is any change in the information contained in the most recently filed certification, the non-state entity shall submit an updated certification no more than thirty (30) days after the effective date of such a change or upon the submittal of any new bid or proposal for a state contract, whichever is earlier. 
 
The following form has been rescinded pursuant to Public Act No. 22-40 and representation has been incorporated into resulting contract language.
Form 2. Rev. 11/18/21. Rescinded on 01-Jul-22 Word

The following forms have been rescinded pursuant to Public Act No. 21-76 and representations have been incorporated into resulting contract language.

Form 2.Rescinded on 01-Aug-07.  Use Form 1.

Form 3. Rescinded on 01-Jul-21. Word. PDF.

Form 4.Rescinded on 01-Aug-07.  Use Form 1.

Form 5. Rescinded on 01-Jul-21. Word. PDF. 

Form 6. Rescinded on 01-Jul-21.Word. 

Forms 6A, 6B, 6C.  Rescinded on 01-Aug-07.  Use Form 6.

Form 7.  Rescinded on 01-Jul-21. Word. PDF. 

More information on historical requirements can be found here.

  • State Contract: General Statutes Sec. 9-612 defines "State contract" as an agreement or contract with the state or any state agency or any quasi-public agency, let through a procurement process or otherwise, having a value of fifty thousand dollars or more, or a combination or series of such agreements or contracts having a value of one hundred thousand dollars or more in a calendar year, for (i) the rendition of services, (ii) the furnishing of any goods, material, supplies, equipment or any items of any kind, (iii) the construction, alteration or repair of any public building or public work, (iv) the acquisition, sale or lease of any land or building, (v) a licensing arrangement, or (vi) a grant, loan or loan guarantee. "State contract" does not include any agreement or contract with the state, any state agency or any quasi-public agency that is exclusively federally funded, an education loan, a loan to an individual for other than commercial purposes or any agreement or contract between the state or any state agency and the United States Department of the Navy or the United States Department of Defense.
  • Value of the contract means the dollar amount (or equivalent benefit) expended or received by the State in accordance with the contract.

    Example:
    OPM entered into an agreement with Pinpoint Power whereby, in the event of a power shortage, certain State agencies may be asked to use their own emergency generators.  In exchange, the contractor pays the State a specified amount of money to compensate for the service interruption.  This contract represents a value received by the State.