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State of Rhode Island and Providence Plantations
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Vendor Affidavit
 
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AFFIDAVIT OF STATE VENDOR
1.
Name, address and telephone number of person making this affidavit
Prefix
First Name
Middle Name
Last Name
Suffix
Street Address
Street Address2
City/Town,
State and Zip Code
 
Phone Number      
 

2.
Within the 24 month period preceding the date of the contract with the state agency, or with respect to the contracts that are not in writing within the 24 month period preceding the date of notification that the contract has reached the $5000 threshold, have you contributed an aggregate amount of more than $250 within a calendar year to any R.I. general officer, candidate for R.I. general office, any member of the general assembly or candidate for general assembly, or any R.I. political party? (includes an individual contracting party, or business entity on behalf of a related party, or a related party reporting on his/her own behalf) NOTE: If this is a semi-annual filing (i.e. January 1 to June 30 or July 1 to December 31), you must report contributions made from the date of execution of the last contract entered into during such semi-annual period to the date which is 24 months prior to the first day of the same semi-annual period.

(If you checked "No", above, do not attach a copy of the state contract, or written summary, and do not complete remainder of form.)