Prison Phone Justice

ϭ͘

DESCRIPTION OF CONTRACT BEING RENEWED: The Illinois Department of Innovation and Technology and
Securus Technologies, >> are renewing Contract # CIT9331500 for phone services for the Department of
Corrections, Department of Juvenile Justice and the Department of Human Services incarcerated persons and
residents. This is renewal 1 of 7.

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TERMS AND CONDITIONS: This Renewal is on the same terms and conditions as the Contract being renewed
except as changed and described herein.

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RENEWAL TERM: This RENEWAL shall begin July 1, 2021 and shall run through June 30, 2022.

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COSTS: This is a Zero Dollar ($0.00) cost contract to the State. All expenses are paid by the incarcerated persons
and residents.

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MAXIMUM AMOUNT: The total payments under this contract shall not exceed $N/A without a formal
amendment.

6.

SUBCONTRACTORS: Will subcontractors be utilized?
x

Yes

No

Subcontractor Name: G5 Tek Solutions, LLC
Amount to be paid: No change from current contract.
Address: 4485 Trench Rd. Suite 2421, Suwanee, GA 30024
Description of work: No change from current contract͘

7.

6.1.

All contracts with the subcontractors identified above must include the Standard Certifications
completed and signed by the subcontractor.

6.2.

If the annual value of any the subcontracts is more than $50,000, then the Vendor must provide
to the State the Financial Disclosures and Conflicts of Interest for that subcontractor.

6.3.

If the subcontractor is registered in the Illinois Procurement Gateway (IPG) and the Vendor is using
the subcontractor’s Standard Certifications or Financial Disclosures and Conflicts of Interest from
the IPG, then the Vendor must also provide a completed Forms B for the subcontractor.

6.4.

If at any time during the term of the Contract, Vendor adds or changes any subcontractors, Vendor
will be required to promptly notify, in writing, the State Purchasing Officer or the Chief
Procurement Officer of the names and addresses and the expected amount of money that each
new or replaced subcontractor will receive pursuant to the Contract. Any subcontracts entered
into prior to award of the Contract are done at the Vendor’s and subcontractor’s risk.

JOINT AND COOPERATIVE PURCHASING ADDITIONAL TERMS AND CONDITIONS:
Agency Definitions
7.1.1

“Chief Procurement Officer” means the chief procurement officer appointed pursuant to 30 ILCS
500/10-20(a)(4).

State of Illinois Renewal with Disclosures
V.15.2

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7.1.2

“Governmental unit” means Illinois Department of Innovation and Technology, Illinois
Department of Corrections, Illinois Department of Juvenile Justice and Illinois Department of
Human Services.
Agency Specific Terms and Conditions

7.2.1

The Chief Procurement Officer for General Services makes this contract available to Illinois
Department of Innovation and Technology, Illinois Department of Corrections, Illinois Department
of Juvenile Justice and Illinois Department of Human Services.

7.2.2

Vendor agrees to extend all terms and conditions, specifications, and pricing or discounts specified
in this contract for the items in this contract to all governmental units listed above in Section 7.1.2.

7.2.3

The supplies or services subject to this Contract shall be distributed or rendered directly to each
governmental unit.

7.2.4

Vendor shall bill each governmental unit separately for its actual share of the costs of the supplies
or services purchased.

7.2.5

The credit or liability of each governmental unit shall remain separate and distinct.

7.2.6

Disputes between vendors and governmental units shall be resolved between the affected parties.

7.2.7

All terms and conditions in this Contract apply with full force and effect to all purchase orders.

State of Illinois Renewal with Disclosures
V.15.2

4

STATE OF ILLINOIS
TAXPAYER IDENTIFICATION NUMBER
I certify that:
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued
to me), and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified
by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest
or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
I am a U.S. person (including a U.S. resident alien).
x

If you are an individual, enter your name and SSN as it appears on your Social Security Card.

x

If you are a sole proprietor, enter the owner’s name on the name line followed by the name of the
business and the owner’s SSN or EIN.

x

If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s
name on the name line and the D/B/A on the business name line and enter the owner’s SSN or EIN.

x

If the LLC is a corporation or partnership, enter the entity’s business name and EIN and for corporations,
attach IRS acceptance letter (CP261 or CP277).

x

For all other entities, enter the name of the entity as used to apply for the entity’s EIN and the EIN.
Name: ǀĞŶƚŝǀ dĞĐŚŶŽůŽŐŝĞƐ͕ >>
Business Name: Securus Technologies, LLC
Taxpayer Identification Number:
Social Security Number:
or
Employer Identification Number: ϳϱͲϮϳϮϮϭϰϰ
Legal Status (check one):
Individual

Governmental

Sole Proprietor

Nonresident alien

Partnership

Estate or trust

Legal Services Corporation

Pharmacy (Non-Corp.)

Tax-exempt

Pharmacy/Funeral Home/Cemetery (Corp.)

Corporation providing or billing

Limited Liability Company

medical and/or health care services

(select applicable tax classification)

Corporation NOT providing or billing

C = corporation

medical and/or health care services

P = partnership

Signature of Authorized Representative:
Date: Wednesday, June 30, 2021

State of Illinois Chief Procurement Office
Taxpayer Identification Number
V.15.2

STATE OF ILLINOIS
STANDARD CERTIFICATIONS

Vendor acknowledges and agrees that compliance with this subsection in its entirety for the term of the contract and
any renewals is a material requirement and condition of this contract. By executing this contract Vendor certifies
compliance with this subsection in its entirety, and is under a continuing obligation to remain in compliance and report
any non-compliance.
This subsection, in its entirety, applies to subcontractors used on this contract. Vendor shall include these Standard
Certifications in any subcontract used in the performance of the contract using the Standard Certification form provided
by the State.
If this contract extends over multiple fiscal years, including the initial term and all renewals, Vendor and its
subcontractors shall confirm compliance with this section in the manner and format determined by the State by the date
specified by the State and in no event later than July 1 of each year that this contract remains in effect.
If the Parties determine that any certification in this section is not applicable to this contract it may be stricken without
affecting the remaining subsections.
4.1.

As part of each certification, Vendor acknowledges and agrees that should Vendor or its subcontractors provide
false information, or fail to be or remain in compliance with the Standard Certification requirements, one or
more of the following sanctions will apply:
•

the contract may be void by operation of law,

•

the State may void the contract, and

•

the Vendor and it subcontractors may be subject to one or more of the following: suspension,
debarment, denial of payment, civil fine, or criminal penalty.

Identifying a sanction or failing to identify a sanction in relation to any of the specific certifications does not
waive imposition of other sanctions or preclude application of sanctions not specifically identified.
4.2.

Vendor certifies it and its employees will comply with applicable provisions of the United States Civil Rights Act,
Section 504 of the Federal Rehabilitation Act, the Americans with Disabilities Act, and applicable rules in
performance of this contract.

4.3.

Vendor, if an individual, sole proprietor, partner or an individual as member of a LLC, certifies he/she is not in
default on an educational loan. 5 ILCS 385/3.

4.4.

Vendor, if an individual, sole proprietor, partner or an individual as member of a LLC, certifies it he/she has not
received (i) an early retirement incentive prior to 1993 under Section 14-108.3 or 16-133.3 of the Illinois Pension
Code or (ii) an early retirement incentive on or after 2002 under Section 14-108.3 or 16-133.3 of the Illinois
Pension Code. 30 ILCS 105/15a; 40 ILCS 5/14-108.3; 40 ILCS 5/16-133.

4.5.

Vendor certifies that it is a legal entity authorized to do business in Illinois prior to submission of a bid, offer, or
proposal. 30 ILCS 500/1-15.80, 20-43.

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Standard Certifications
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STATE OF ILLINOIS
STANDARD CERTIFICATIONS
4.6.

To the extent there was a current Vendor providing the services covered by this contract and the employees of
that Vendor who provided those services are covered by a collective bargaining agreement, Vendor certifies (i)
that it will offer to assume the collective bargaining obligations of the prior employer, including any existing
collective bargaining agreement with the bargaining representative of any existing collective bargaining unit or
units performing substantially similar work to the services covered by the contract subject to its bid or offer; and
(ii) that it shall offer employment to all employees currently employed in any existing bargaining unit who
perform substantially similar work to the work that will be performed pursuant to this contract. This does not
apply to heating, air conditioning, plumbing and electrical service contracts. 30 ILCS 500/25-80.

4.7.

Vendor certifies it has neither been convicted of bribing or attempting to bribe an officer or employee of the
State of Illinois or any other State, nor made an admission of guilt of such conduct that is a matter of record. 30
ILCS 500/50-5.

4.8.

If Vendor has been convicted of a felony, Vendor certifies at least five years have passed after the date of
completion of the sentence for such felony, unless no person held responsible by a prosecutor’s office for the
facts upon which the conviction was based continues to have any involvement with the business. 30 ILCS
500/50-10.

4.9.

If Vendor or any officer, director, partner, or other managerial agent of Vendor has been convicted of a felony
under the Sarbanes-Oxley Act of 2002, or a Class 3 or Class 2 felony under the Illinois Securities Law of 1953,
Vendor certifies at least five years have passed since the date of the conviction. Vendor further certifies that it
is not barred from being awarded a contract and acknowledges that the State shall declare the contract void if
this certification is false. 30 ILCS 500/50-10.5.

4.10.

Vendor certifies it is not barred from having a contract with the State based upon violating the prohibitions
related to either submitting/writing specifications or providing assistance to an employee of the State of Illinois
by reviewing, drafting, directing, or preparing any invitation for bids, a request for proposal, or request of
information, or similar assistance (except as part of a public request for such information). 30 ILCS 500/5010.5(e), amended by Pub. Act No. 97-0895 (August 3, 2012).

4.11.

Vendor certifies that it and its affiliates are not delinquent in the payment of any debt to the State (or if
delinquent has entered into a deferred payment plan to pay the debt), and Vendor and its affiliates
acknowledge the State may declare the contract void if this certification is false or if Vendor or an affiliate later
becomes delinquent and has not entered into a deferred payment plan to pay off the debt. 30 ILCS 500/50-11,
50-60.

4.12.

Vendor certifies that it and all affiliates shall collect and remit Illinois Use Tax on all sales of tangible personal
property into the State of Illinois in accordance with provisions of the Illinois Use Tax Act and acknowledges that
failure to comply may result in the contract being declared void. 30 ILCS 500/50-12.

4.13.

Vendor certifies that it has not been found by a court or the Pollution Control Board to have committed a willful
or knowing violation of the Environmental Protection Act within the last five years, and is therefore not barred
from being awarded a contract. 30 ILCS 500/50-14.

4.14.

Vendor certifies it has neither paid any money or valuable thing to induce any person to refrain from bidding on
a State contract, nor accepted any money or other valuable thing, or acted upon the promise of same, for not
bidding on a State contract. 30 ILCS 500/50-25.

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Standard Certifications
V.18.1

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STATE OF ILLINOIS
STANDARD CERTIFICATIONS
4.15.

Vendor certifies it is not in violation of the “Revolving Door” provisions of the Illinois Procurement Code. 30 ILCS
500/50-30.

4.16.

Vendor certifies that it has not retained a person or entity to attempt to influence the outcome of a
procurement decision for compensation contingent in whole or in part upon the decision or procurement. 30
ILCS 500/50-38.

4.17.

Vendor certifies that if it has hired a person required to register under the Lobbyist Registration Act to assist in
obtaining any State contract, that none of the lobbyist’s costs, fees, compensation, reimbursements, or other
remuneration were billed to the State. 30 ILCS 500/50-38.

4.18.

Vendor certifies it will report to the Illinois Attorney General and the Chief Procurement Officer any suspected
collusion or other anti-competitive practice among any bidders, offerors, contractors, proposers, or employees
of the State. 30 ILCS 500/50-40, 50-45, 50-50.

4.19.

Vendor certifies steel products used or supplied in the performance of a contract for public works shall be
manufactured or produced in the United States, unless the executive head of the procuring Agency grants an
exception. 30 ILCS 565.

4.20.

Drug Free Workplace
4.20.1. If Vendor employs 25 or more employees and this contract is worth more than $5,000, Vendor certifies
it will provide a drug free workplace pursuant to the Drug Free Workplace Act.
4.20.2. If Vendor is an individual and this contract is worth more than $5000, Vendor certifies it shall not engage
in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance
during the performance of the contract. 30 ILCS 580.

4.21.

Vendor certifies that neither Vendor nor any substantially owned affiliate is participating or shall participate in
an international boycott in violation of the U.S. Export Administration Act of 1979 or the applicable regulations
of the United States. Department of Commerce. 30 ILCS 582.

4.22.

Vendor certifies it has not been convicted of the offense of bid rigging or bid rotating or any similar offense of
any state or of the United States. 720 ILCS 5/33 E-3, E-4.

4.23.

Vendor certifies it complies with the Illinois Department of Human Rights Act and rules applicable to public
contracts, which include providing equal employment opportunity, refraining from unlawful discrimination, and
having written sexual harassment policies. 775 ILCS 5/2-105.

4.24.

Vendor certifies it does not pay dues to or reimburse or subsidize payments by its employees for any dues or
fees to any “discriminatory club.” 775 ILCS 25/2.

4.25.

Vendor certifies that no foreign-made equipment, materials, or supplies furnished to the State under the
contract have been or will be produced in whole or in part by forced labor or indentured labor under penal
sanction. 30 ILCS 583.

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Standard Certifications
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STATE OF ILLINOIS
STANDARD CERTIFICATIONS
4.26.

Vendor certifies that no foreign-made equipment, materials, or supplies furnished to the State under the
contract have been produced in whole or in part by the labor of any child under the age of 12. 30 ILCS 584.

4.27.

Vendor certifies that any violation of the Lead Poisoning Prevention Act, as it applies to owners of residential
buildings, has been mitigated. 410 ILCS 45.

4.28.

Vendor warrants and certifies that it and, to the best of its knowledge, its subcontractors have and will comply
with Executive Order No. 1 (2007). The Order generally prohibits Vendors and subcontractors from hiring the
then-serving Governor’s family members to lobby procurement activities of the State, or any other unit of
government in Illinois including local governments if that procurement may result in a contract valued at over
$25,000. This prohibition also applies to hiring for that same purpose any former State employee who had
procurement authority at any time during the one-year period preceding the procurement lobbying activity.

4.29.

Vendor certifies that information technology, including electronic information, software, systems and
equipment, developed or provided under this contract comply with the applicable requirements of the Illinois
Information Technology Accessibility Act Standards as published at (www.dhs.state.il.us/iitaa) 30 ILCS 587.

4.30.

Vendor certifies that it has read, understands, and is in compliance with the registration requirements of the
Elections Code (10 ILCS 5/9-35) and the restrictions on making political contributions and related requirements
of the Illinois Procurement Code. 30 ILCS 500/20-160 and 50-37. Vendor will not make a political contribution
that will violate these requirements.
In accordance with section 20-160 of the Illinois Procurement Code, Vendor certifies as applicable:
Vendor is not required to register as a business entity with the State Board of Elections.
or
Vendor has registered with the State Board of Elections. As a registered business entity, Vendor
acknowledges a continuing duty to update the registration as required by the Act.

4.31.

Vendor certifies that if it is awarded a contract through the use of the preference required by the Procurement
of Domestic Products Act, then it shall provide products pursuant to the contract or a subcontract that are
manufactured in the United States. 30 ILCS 517.

4.32.

For contracts other than construction contracts subject to the requirements of 30 ILCS 500/30-20 and 30 ILCS
500/33-10, a person (other than an individual acting as a sole proprietor) must be a duly constituted legal entity
to qualify as a bidder or offeror prior to submitting a bid, offer, or proposal. 30 ILCS 500/20-43. Vendor certifies
that it is a legal entity as of the date for submitting this bid, offer, or proposal.

4.33.

Vendor certifies that, for the duration of this contract it will:
•
•

post its employment vacancies in Illinois and border states on the Department of Employment Security’s
IllinoisJobLink.com website or its successor system; or
will provide an online link to these employment vacancies so that this link is accessible through the
IllinoisJobLink.com website it successor system; or

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Standard Certifications
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STATE OF ILLINOIS
STANDARD CERTIFICATIONS
•

is exempt from 20 ILCS 1005/1005-47 because the contract is for construction-related services as that
term is defined in section 1-15.20 of the Procurement Code; or the contract is for construction and
vendor is a party to a contract with a bona fide labor organization and performs construction. (20 ILCS
1005/1005-47).

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Standard Certifications
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STATE OF ILLINOIS
STATE BOARD OF ELECTIONS
5.

Section 50-37 of the Illinois Procurement Code prohibits political contributions of certain vendors, bidders and
offerors. Additionally, section 9-35 of the Illinois Election Code governs provisions relating to reporting and
making contributions to state officeholders, declared candidates for State offices and covered political
organizations that promote the candidacy of an officeholder or declared candidate for office. The State may
declare any resultant contract void if these Acts are violated.
Generally, if a vendor, bidder, or offeror is an entity doing business for profit (i.e. sole proprietorship,
partnership, corporation, limited liability company or partnership, or otherwise) and has contracts with State
agencies that annually total more than $50,000 or whose aggregate pending bids or proposals and current State
contracts that total more than $50,000, the vendor, bidder, or offeror is prohibited from making political
contributions and must register with the State Board of Elections. 30 ILCS 500/20-160.
EVIDENCE OF REGISTRATION WITH THE STATE BOARD OF ELECTIONS
IS THE CERTIFICATE OF REGISTRATION

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: State Board of Elections
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STATE OF ILLINOIS
DISCLOSURE OF BUSINESS OPERATIONS WITH IRAN
6.

In accordance with 30 ILCS 500/50-36, each bid, offer, or proposal submitted for a State contract, other than a
small purchase defined in Section 20-20 of the Illinois Procurement Code, will include a disclosure of whether or
not the bidder, offeror, or proposing entity, or any of its corporate parents or subsidiaries, within the 24 months
before submission of the bid, offer, or proposal had business operations that involved contracts with or
provision of supplies or services to the Government of Iran, companies in which the Government of Iran has any
direct or indirect equity share, consortiums or projects commissioned by the Government of Iran and:
•

more than 10% of the company’s revenues produced in or assets located in Iran involve oil-related
activities or mineral-extraction activities; less than 75% of the company’s revenues produced in or assets
located in Iran involve contracts with or provision of oil-related or mineral – extraction products or
services to the Government of Iran or a project or consortium created exclusively by that Government;
and the company has failed to take substantial action; or

•

the company has, on or after August 5, 1996, made an investment of $20 million or more, or any
combination of investments of at least $10 million each that in the aggregate equals or exceeds $20
million in any 12- month period that directly or significantly contributes to the enhancement of Iran’s
ability to develop petroleum resources of Iran.

A bid or offer that does not include this disclosure may be given a period after the bid or offer is submitted to
cure non-disclosure. A chief procurement officer may consider the disclosure when evaluating the bid or offer
or awarding the contract.
 There are no business operations that must be disclosed to comply with the above cited law.
The following business operations are disclosed to comply with the above cited law:

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Disclosure of Business Operations with Iran
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STATE OF ILLINOIS
FINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST
The Financial Disclosures and Conflicts of Interest form (“form”) must be accurately completed and submitted by the
vendor, parent entity(ies), and subcontractors. There are nine steps to this form and each must be completed as
instructed in the step heading and within the step. A bid or offer that does not include this form shall be considered
non-responsive. The Agency will consider this form when evaluating the bid or offer or awarding the contract.
The requirement of disclosure of financial interests and conflicts of interest is a continuing obligation. If circumstances
change and the disclosure is no longer accurate, then disclosing entities must provide an updated form.
Separate forms are required for the vendor, parent entity(ies), and subcontractors.
This disclosure is submitted for:
 Vendor
Vendor’s Parent Entity(ies) (100% ownership)
Subcontractor(s) >$50,000 (annual value)
Subcontractor’s Parent Entity(ies) (100% ownership) > $50,000 (annual value)
Project Name

Renewal of Illnois Phone Services for Incarcerated Persons

Illinois Procurement Bulletin
Number
Contract Number
Vendor Name

CIT9331500
Securus Technologies, LLC

Doing Business As (DBA)
Disclosing Entity
Disclosing Entity’s Parent
Entity

Securus Technologies, LLC
Aventiv Technologies, LLC

Subcontractor
Instrument of Ownership or
Beneficial Interest

LLC, partnership, privately held corporation with 100 or fewer shareholders, or other entity type not clearly identified in another option)

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
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FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS

STEP 1
SUPPORTING DOCUMENTATION SUBMITTAL
(All vendors complete regardless of annual bid, offer, or contract value)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
You must select one of the six options below and select the documentation you are submitting. You must provide the
documentation that the applicable section requires with this form.
Option 1 – Publicly Traded Entities
1.A.

Complete Step 2, Option A for each qualifying individual or entity holding any ownership or
distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the
annual salary of the Governor.
OR

1.B.

Attach a copy of the Federal 10-K or provide a web address of an electronic copy of the Federal
10-K, and skip to Step 3.

Option 2 – Privately Held Entities with more than 100 Shareholders
2.A.

Complete Step 2, Option A for each qualifying individual or entity holding any ownership or
distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the
annual salary of the Governor.
OR

2.B.

Complete Step 2, Option A for each qualifying individual or entity holding any ownership share
in excess of 5% and attach the information Federal 10-K reporting companies are required to
report under 17 CFR 229.401.

Option 3 – All other Privately Held Entities, not including Sole Proprietorships
3.A.

Complete Step 2, Option A for each qualifying individual or entity holding any ownership or
distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the
annual salary of the Governor.

Option 4 – Foreign Entities
4.A.

Complete Step 2, Option A for each qualifying individual or entity holding any ownership or
distributive income share in excess of 5% or an amount greater than 60% ($106,447.20) of the
annual salary of the Governor.
OR

4.B.

Attach a copy of the Securities Exchange Commission Form 20-F or 40-F and skip to Step 3.

Option 5 – Not-for-Profit Entities
Complete Step 2, Option B.
Option 6 – Sole Proprietorships
Skip to Step 3.
State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
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FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS

STEP 2
DISCLOSURE OF FINANCIAL INTEREST OR BOARD OF DIRECTORS
(All vendors, except sole proprietorships, must complete regardless of annual bid, offer, or contract value)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
Complete either Option A (for all entities other than not-for-profits) or Option B (for not-for-profits). Additional rows
may be inserted into the tables or an attachment may be provided if needed.

OPTION A – Ownership Share and Distributive Income
Ownership Share – If you selected Option 1.A., 2.A., 2.B., 3.A., or 4.A. in Step 1, provide the name and address of each
individual or entity and their percentage of ownership if said percentage exceeds 5%, or the dollar value of their
ownership if said dollar value exceeds $106,447.20.
Check here if including an attachment with requested information in a format substantially similar to the format
below. Attaching corporate structure diagram

TABLE – X
Name

Address

Aventiv Technologies, LLC 4000 International Parkway

Percentage of Ownership

$ Value of Ownership

100%

Not publically available

Distributive Income – If you selected Option 1.A., 2.A., 3.A., or 4.A. in Step 1, provide the name and address of each
individual or entity and their percentage of the disclosing vendor’s total distributive income if said percentage exceeds
5% of the total distributive income of the disclosing entity, or the dollar value of their distributive income if said dollar
value exceeds $106,447.20.
Check here if including an attachment with requested information in a format substantially similar to the format
below.

TABLE – Y
Name

Address

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
V.18.1

% of Distributive Income

$ Value of Distributive Income

16

FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS
Please certify that the following statements are true.
I have disclosed all individuals or entities that hold an ownership interest of greater than 5% or greater than
$106,447.20.
Yes

No

I have disclosed all individuals or entities that were entitled to receive distributive income in an amount greater
than $106,447.20 or greater than 5% of the total distributive income of the disclosing entity.
Yes

No

OPTION B – Disclosure of Board of Directors (Not-for-Profits)
If you selected Option 5 in Step 1, list members of your board of directors. Please include an attachment if necessary.

TABLE – Z
Name

Address

Click here to enter text.

Click
here to
enter
text.
Click
here to
enter
text.
Click
here to
enter
text.

Click here to enter text.

Click here to enter text.

STEP 3
DISCLOSURE OF LOBBYIST OR AGENT
(Complete only if bid, offer, or contract has an annual value over $50,000)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
Yes
No. Is your company represented by or do you employ a lobbyist required to register under the Lobbyist
Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or other agent who is not
identified through Step 2, Option A above and who has communicated, is communicating, or may communicate with any
State officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name
and address below.
If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist’s information.

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
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FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS
Name

Address

Relationship to Disclosing Entity

Click here to enter text.

Click here to enter text.

Click here to enter text.

Describe all costs/fees/compensation/reimbursements related to the assistance provided by each representative
lobbyist or other agent to obtain this Agency contract: Click here to enter text.

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
V.18.1

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FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS

STEP 4
PROHIBITED CONFLICTS OF INTEREST
(All vendors must complete regardless of annual bid, offer, or contract value)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
Step 4 must be completed for each person disclosed in Step 2, Option A and for sole proprietors identified in Step
1, Option 6 above. Please provide the name of the person for which responses are provided: Securus
Technologies, LLC
1.

Do you hold or are you the spouse or minor child who holds an elective office in the State of
Illinois or hold a seat in the General Assembly?

Yes

No

2.

Have you, your spouse, or minor child been appointed to or employed in any offices or
agencies of State government and receive compensation for such employment in excess of
60% ($106,447.20) of the salary of the Governor?

Yes

No

3.

Are you or are you the spouse or minor child of an officer or employee of the Capital
Development Board or the Illinois Toll Highway Authority?

Yes

No

4.

Have you, your spouse, or an immediate family member who lives in your residence
currently or who lived in your residence within the last 12 months been appointed as a
member of a board, commission, authority, or task force authorized or created by State law
or by executive order of the Governor?

Yes

No

5.

If you answered yes to any question in 1-4 above, please answer the following: Do you, your
spouse, or minor child receive from the vendor more than 7.5% of the vendor’s total
distributable income or an amount of distributable income in excess of the salary of the
Governor ($177,412.00)?

Yes

No

6.

If you answered yes to any question in 1-4 above, please answer the following: Is there a
combined interest of self with spouse or minor child more than 15% in the aggregate of the
vendor’s distributable income or an amount of distributable income in excess of two times
the salary of the Governor ($354,824.00)?

Yes

No

STEP 5
POTENTIAL CONFLICTS OF INTEREST RELATING TO PERSONAL RELATIONSHIPS
(Complete only if bid, offer, or contract has an annual value over $50,000)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
Step 5 must be completed for each person disclosed in Step 2, Option A and for sole proprietors identified in Step
1, Option 6 above. Securus Technologies.com

1.
2.

Do you currently have, or in the previous 3 years have you had State employment, including
contractual employment of services?
Has your spouse, father, mother, son, or daughter, had State employment, including
contractual employment for services, in the previous 2 years?

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
V.18.1

Yes

No

Yes

No
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FINANCIAL DISCLOSURES AND CONFLICTS OF INTERESTS

3.

Do you hold currently or have you held in the previous 3 years elective office of the State of
Illinois, the government of the United States, or any unit of local government authorized by
the Constitution of the State of Illinois or the statutes of the State of Illinois?

Yes

No

4.

Do you have a relationship to anyone (spouse, father, mother, son, or daughter) holding
elective office currently or in the previous 2 years?

Yes

No

5.

Do you hold or have you held in the previous 3 years any appointive government office of
the State of Illinois, the United States of America, or any unit of local government authorized
by the Constitution of the State of Illinois or the statutes of the State of Illinois, which office
entitles the holder to compensation in excess of expenses incurred in the discharge of that
office?

Yes

No

6.

Do you have a relationship to anyone (spouse, father, mother, son, or daughter) holding
appointive office currently or in the previous 2 years?

Yes

No

7.

Do you currently have or in the previous 3 years had employment as or by any registered
lobbyist of the State government?

Yes

No

8.

Do you currently have or in the previous 2 years had a relationship to anyone (spouse,
father, mother, son, or daughter) that is or was a registered lobbyist?

Yes

No

9.

Do you currently have or in the previous 3 years had compensated employment by any
registered election or re-election committee registered with the Secretary of State or any
county clerk in the State of Illinois, or any political action committee registered with either
the Secretary of State or the Federal Board of Elections?

Yes

No

10.

Do you currently have or in the previous 2 years had a relationship to anyone (spouse,
father, mother, son, or daughter) who is or was a compensated employee of any registered
election or reelection committee registered with the Secretary of State or any county clerk in
the State of Illinois, or any political action committee registered with either the Secretary of
State or the Federal Board of Elections?

Yes

No

STEP 6
EXPLANATION OF AFFIRMATIVE RESPONSES
(All vendors must complete regardless of annual bid, offer, or contract value)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
If you answered “Yes” in Step 4 or Step 5, please provide on an additional page a detailed explanation that includes, but
is not limited to the name, salary, State agency or university, and position title of each individual.

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
V.18.1

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FINANCIAL DISCLOSURES AND CONFLICTS OF INTEREST

STEP 7
POTENTIAL CONFLICTS OF INTEREST
RELATING TO DEBARMENT & LEGAL PROCEEDINGS
(Complete only if bid, offer, or contract has an annual value over $50,000)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
This step must be completed for each person disclosed in Step 2, Option A, Step 3, and for each entity and sole
proprietor disclosed in Step 1.
Please provide the name of the person or entity for which responses are provided: Securus Technologies, LLC
1.

Within the previous ten years, have you had debarment from contracting with any
governmental entity?

Yes

No

2.

Within the previous ten years, have you had any professional licensure discipline?

Yes

No

3.

Within the previous ten years, have you had any bankruptcies?

Yes

No

4.

Within the previous ten years, have you had any adverse civil judgments and administrative
findings?

Yes

No

5.

Within the previous ten years, have you had any criminal felony convictions?

Yes

No

If you answered “Yes”, please provide a detailed explanation that includes, but is not limited to the name, State agency
or university, and position title of each individual. Click here to enter text.

STEP 8
DISCLOSURE OF CURRENT AND PENDING CONTRACTS
(Complete only if bid, offer, or contract has an annual value over $50,000)
(Subcontractors with subcontract annual value of more than $50,000 must complete)
If you selected Option 1, 2, 3, 4, or 6 in Step 1, do you have any contracts, pending contracts, bids, proposals,
subcontracts, leases or other ongoing procurement relat+ionships with units of State of Illinois government?
Yes

No.

If “Yes”, please specify below. Additional rows may be inserted into the table or an attachment may be provided if
needed.
Agency

Project Title

Status

Value

Contract
Reference/P.O./Illinois
Procurement Bulletin #

CMS/DOC

Inmate Calling Services

Active

$18,000,000

CM3670940

State of Illinois Chief Procurement Office General Services
IFB or RFP Solicitation: Forms A: Financial Disclosures and Conflicts of Interest
V.18.1

21