No invoices dated prior to receiving a completed application will be reimbursed.

Transcription

1 Kentucky Department of Agriculture Commissioner Ryan F. Quarles Kentucky Proud Restaurant Rewards Program Guidelines Kentucky Proud Certificate Number: Foodservices may be reimbursed up to 20% of the purchase cost for eligible products. The foodservice is required to promote the brand and is subject to an audit by Kentucky Department of Agriculture (KDA). The reimbursement maximum is $12,000 within a 12 month timeframe, with a life time cap of $36,000 or until funds are exhausted. No invoices dated prior to receiving a completed application will be reimbursed. Foodservices should contact KDA prior to purchase with any eligibility concerns. Products purchased before the contract agreement is signed and received by KDA are not eligible. ALL CONTRACTS MUST BE RECEIVED PRIOR TO ANY PURCHASES! You have completed your application and contract if you have included ALL of the following REQUIRED information: You are a member in good standing and active You have signed all application and Contract forms You have completed the score rubrics You have included your signed and notarized Required Affidavit for Bidders You have included your completed W-9 You have listed Kentucky proud vendors you purchase from You have submitted a sample of your promotion efforts You have submitted proof/documentation of stated % of products on your menu Eligible Products Products must have direct farm gate value, i.e. purchased from a farm in whole product, or processed products containing 100% Kentucky grown products by a member. Kentucky Produce: any type of produce intended for consumption is eligible for the program. All produce (100%) must have been grown in Kentucky. Kentucky Meat, Fish, Dairy, and Eggs: all meat originating from livestock and poultry raised in Kentucky and eggs produced entirely in Kentucky are eligible for the program. o Fluid milk (pasteurized, reduced fat, low fat, and skim milk products) processed at a Kentucky Proud member facility located in KY will be eligible after July 31, 2016, but the reimbursement for these products can not exceed 25% of the total approved reimbursement per request form. Additional value added dairy products including cheese, cream, butter, ice cream, and yogurt processed by a Kentucky Proud member in KY that uses milk processed at one of the above fluid milk plants or from Kentucky farms will be eligible under the same terms as above. o With appropriate tracking documentation, meat produced in Kentucky, but processed in a USDA inspected facility outside of Kentucky is eligible with direct Kentucky farm tractability because of Kentucky s limited access to inspected plants. o All aquaculture products raised or harvested in Kentucky are eligible with direct Kentucky farm tractability. o Kentucky wines containing 75% Kentucky grown grapes are eligible. Kentucky Value-Added Products: products such as wine, jams, jellies, sauces, etc. are eligible for the program if the producer of the products can document that at least 90% (75% for wine) of the product ingredients were grown or produced in Kentucky. Products for re-sale are NOT eligible. Kentucky Department of Agriculture 111 Corporate Drive Frankfort, KY Angela Caporelli angela.caporelli@ky.gov 1

2 Please read carefully as several things have changed! Kentucky Proud Certificate Number: KENTUCKY DEPARTMENT OF AGRICULTURE RESTAURANT REWARDS PROGRAM AGREEMENT This AGREEMENT, made and entered into this day of, 20, by and between the Kentucky Department of Agriculture (KDA) and, a licensed foodservice (the Foodservice). THE PARTIES AGREE AS FOLLOWS: A. The Foodservice Partner agrees: 1. MUST be a member of! And follow all requirements. 2. To confirm products are eligible for reimbursement prior to purchasing the products. 3. To contact the KDA when any product is in question. 4. To document the purchases of eligible Kentucky products, producers, and suppliers on the Reimbursement Request Form (incorporated by reference). 5. To document the promotion of the brand. 6. To submit requests for reimbursement within 90 days of the food purchase. 7. To comply with the Restaurant Rewards Program Guidelines, (incorporated by reference). 8. To promote the brand to customers while maintaining the character of the business model. 9. To allow the KDA to audit the promotion of the brand through on-site audits. 10. To purchase, at-cost, any promotional items desired for events or resale. B. The Kentucky Department of Agriculture, as authorized by KRS , agrees: 1. To reimburse the Foodservice at a rate up to 20 cents per one dollar spent on eligible products, not to exceed $12,000 in a 12 month period or $36,000 life time cap. 2. To pay the Foodservice within 60 days of receiving an approved reimbursement request, pending availability of funds. 3. To provide the Foodservice with a limited number of promotional items and marketing material. 4. To include the Foodservice in promotions or special events when appropriate. 5. To abide by all regulations set forth by the Kentucky Agriculture Development Board, Grantor for the Restaurant Rewards Program. C. It is mutually agreed: 1. The KDA is not responsible for reimbursement of food costs associated with products deemed ineligible. 2. If is determined that the Foodservice Partner is not promoting the brand, it will be ineligible for the Restaurant Rewards Program for 12 months from the KDA audit date. 2

3 3. The KDA will reimburse the Foodservice until it has reached the $12,000 maximum in 12 months, $36,000 life time cap, or until funding has been depleted. 4. Only products purchased after the contract approval date are eligible for reimbursement. 5. Foodservice Partner will be assigned a Reimbursement Rate and will only be eligible for recalculation at 6 month intervals. Reimbursement Rate: Rate of reimbursement will be based on the Foodservice score rating established through completion of the Reimbursement Rate Calculation Form provided. This score; reflective of the establishments use and promotion of direct farm products and products and Kentucky agriculture, will determine the actual rate which enters into the calculation for percentage of the maximum 20% eligibility. WITNESSETH, this agreement is executed, by and on behalf of the parties hereto, on the day and the year set forth herein. Signed Executive Director, Kentucky Department of Agriculture Signed Foodservice Director/Purchaser Printed Foodservice Director/Purchaser Payee Information: Foodservice Name Mailing Address Telephone Fax # Tax Status (check one): Social Security Number: (A) Individual (B) Sole Proprietorship (C) Partnership (D) Estate/Trust or (E) Corporation Employer Tax ID Number: (F) Public Service Corporation (G) Governmental/Non-Profit -- 3

4 Agreement Clauses 1. This Agreement is not effective until the Secretary of Finance and Administration Cabinet or his authorized designee has approved the contract and the contract has been filed with the Government Contract Review Committee in accordance with KRS 45A The term of this Agreement shall expire December 31, Payments on personal service contracts and memoranda of agreements shall not be authorized for services rendered after Government Contract Review Committee disapproval, unless the decision of the committee is overridden by the secretary of the Finance and Administration Cabinet or agency head, if the agency has been granted delegation authority. 3. The Grantee agrees that, at any time this Agreement or any renewals of it shall be in effect, if funds are not appropriated to the Grantor or are not otherwise available for the purpose of making payments, the Grantor shall be authorized, upon thirty (30) days written notice to the Grantee, to terminate this contract. Such termination shall be without any other obligation or liability on the part of the Grantor. 4. Either party may cancel this Agreement at any time for cause or may cancel without cause upon 30 days written notice. 5. The Grantee agrees that, at any time this Agreement or any renewals of it shall be in effect, the Kentucky General Assembly may allow for a reduction in contract worker hours in conjunction with a budget balancing measure for some professional and non-professional service contracts. If under such authority the agency is required by Executive Order or otherwise to reduce contract hours, the contract will be reduced by the amount specified in that document. 6. Upon expiration of the initial term, the contract may be renewed in accordance with the terms and conditions in the original solicitation. Renewal shall be subject to prior approval from the Secretary of the Finance and Administration Cabinet or his authorized designee and the LRC Government Contract Review Committee in accordance with KRS 45A.695 and KRS 45A.705, and contingent upon available funding. 7. Pursuant to KRS 45A.725, LRC has established policies which govern rates payable for certain professional services. These are located on the LRC webpage ( and would impact any contract established under KRS 45A.690 et seq., where applicable. 8. All questions as to the execution, validity, interpretation, construction and performance of this agreement shall be governed by the laws of the Commonwealth of Kentucky. Furthermore, the parties hereto agree that any legal action which is brought on the basis of this agreement shall be filed in the Franklin County Circuit Court of the Commonwealth of Kentucky. 9. The Grantee affirms that it is properly authorized under the laws of the Commonwealth of Kentucky to conduct business in this state and will remain in good standing to do business in the Commonwealth of Kentucky for the duration of any contract awarded. 4

5 The Grantee shall maintain certification of authority to conduct business in the Commonwealth of Kentucky during the term of this Contract. Such registration is obtained from the Secretary of State, who will also provide the certification thereof. 10. Pursuant to KRS 45A.480(1)(b), an agency, department, office, or political subdivision of the Commonwealth of Kentucky shall not award a state contract to a person that is a foreign entity required by KRS 14A to obtain a certificate of authority to transact business in the Commonwealth ( certificate ) from the Secretary of State under KRS 14A unless the person produces the certificate within fourteen (14) days of the bid or proposal opening. Therefore, foreign entities should submit a copy of their certificate with their solicitation response. If the foreign entity is not required to obtain a certificate as provided in KRS 14A.9-010, the foreign entity should identify the applicable exception in its solicitation response. Foreign entity is defined within KRS 14A For all foreign entities required to obtain a certificate of authority to transact business in the Commonwealth, if a copy of the certificate is not received by the contracting agency within the time frame identified above, the foreign entity s solicitation response shall be deemed non-responsive or the awarded contract shall be cancelled. Businesses can register with the Secretary of State at The Grantee shall be paid for no travel expenses unless and except as specifically authorized by the specifications of the contract. 12. The Grantee shall be reimbursed for no other expenses of any kind, unless and except as specifically authorized within the specifications of the contract. 13. The Grantee certifies that he will not attempt in any manner to influence any specifications to be restrictive in any way or respect nor will he attempt in any way to influence any purchasing of services, commodities or equipment by the Commonwealth of Kentucky. For the purpose of this paragraph and the following paragraph that pertains to conflict-of interest laws and principles, "he" is construed to mean "they" if more than one person is involved and if a firm, partnership, corporation, or other organization is involved, then "he" is construed to mean any person with an interest therein. 14. The Grantee certifies that he is legally entitled to enter into this contract with the Commonwealth of Kentucky, and by holding and performing this contract will not be violating either any conflict of interest statute (KRS 45A A.340, 45A.990, ), or KRS 11A.040 of the executive branch code of ethics, relating to the employment of former public servants. 15. The Grantee certifies that neither he/she nor any member of his/her immediate family having an interest of 10% or more in any business entity involved in the performance of this contract, has contributed more than the amount specified in KRS (2), to the campaign of the gubernatorial candidate elected at the election last preceding the date of this contract. The Grantee further swears under the penalty of perjury, as provided by KRS , that neither he/she nor the company which he/she represents, has knowingly violated any provisions of the campaign finance laws of the Commonwealth, and that the award of a 5

6 contract to him/her or the company which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth. 16. The Grantee, as defined in KRS 45A.030 (9) agrees that the contracting agency, the Finance and Administration Cabinet, the Auditor of Public Accounts, and the Legislative Research Commission, or their duly authorized representatives, shall have access to any books, documents, papers, records, or other evidence, which are directly pertinent to this contract for the purpose of financial audit or program review. Records and other prequalification information confidentially disclosed as part of the bid process shall not be deemed as directly pertinent to the contract and shall be exempt from disclosure as provided in KRS (1)(c). The Grantee also recognizes that any books, documents, papers, records, or other evidence, received during a financial audit or program review shall be subject to the Kentucky Open Records Act, KRS to In the event of a dispute between the Grantee and the contracting agency, Attorney General, or the Auditor of Public Accounts over documents that are eligible for production and review, the Finance and Administration Cabinet shall review the dispute and issue a determination, in accordance with Secretary's Order Pursuant to KRS 45A.285, The Secretary of the Finance and Administration Cabinet, or his designee, shall have authority to determine protests and other controversies of actual or prospective Vendors in connection with the solicitation or selection for award of a Master Agreement or Contract. 18. Any actual or prospective Vendor, who is aggrieved in connection with the solicitation or selection for award of a Master Agreement or Contract, may file protest with the Secretary of the Finance and Administration Cabinet. A protest or notice of other controversy must be filed promptly and in any event within two (2) calendar weeks after such aggrieved person knows or should have known of the facts giving rise thereto. All protests or notices of other controversies must be in writing and shall be addressed to: William M. Landrum III, Secretary Commonwealth of Kentucky Finance and Administration Cabinet Room 383, New Capitol Annex 702 Capitol Avenue Frankfort, KY The Secretary of Finance and Administration Cabinet shall promptly issue a decision in writing. A copy of that decision shall be mailed or otherwise furnished to the aggrieved party and shall state the reasons for the action taken. The decision by the Secretary of the Finance and Administration Cabinet shall be final and conclusive. Social security: (check one) the parties are cognizant that the state is not liable for social security contributions pursuant to 42 U.S. Code, section 418, relative to the compensation of the second party for this contract. 6

7 the parties are cognizant that the state is liable for social security contributions pursuant to 42 U.S. Code, section 418, relative to the compensation of the second party for this contract. 19. KRS 45A.485 requires the Grantee to reveal to the Commonwealth, prior to the award of a contract, any final determination of a violation by the Grantee within the previous five (5) year period of the provisions of KRS chapters 136, 139, 141, 337, 338, 341, and 342. These statutes relate to the state sales and use tax, corporate and utility tax, income tax, wages and hours laws, occupational safety and health laws, unemployment insurance laws, and workers compensation insurance laws, respectively. To comply with the provisions of KRS 45A.485, the Grantee shall report any such final determination(s) of violation(s) to the Commonwealth by providing the following information regarding the final determination(s): the KRS violated, the date of the final determination, and the state agency which issued the final determination. KRS 45A.485 also provides that, for the duration of any contract, the Grantee shall be in continuous compliance with the provisions of those statutes which apply to the Grantee's operations, and that the Grantee's failure to reveal a final determination as described above or failure to comply with the above statutes for the duration of the contract, shall be grounds for the Commonwealth's cancellation of the contract and the Grantee's disqualification from eligibility for future state contracts for a period of two (2) years. Grantee must check one: The Grantee has not violated any of the provisions of the above statutes within the previous five (5) year period. the Grantee has violated the provisions of one or more of the above statutes within the previous five (5) year period and has revealed such final determination(s) of violation(s). A list of such determination(s) is attached. 20. Discrimination (because of race, religion, color, national origin, sex, sexual orientation, gender identity, age, or disability) prohibited. This section applies only to contracts utilizing federal funds, in whole or in part. During the performance of this contract, the Grantee agrees as follows: 1. The Grantee will not discriminate against any employee or applicant for employment because of race, religion, color, national origin, sex, sexual orientation, gender identity, or age. The Grantee further agrees to comply with the provisions of the Americans with Disabilities Act (ADA), Public Law , and applicable federal regulations relating thereto prohibiting discrimination against otherwise qualified disabled individuals under any program or activity. The Grantee agrees to provide, upon request, needed reasonable accommodations. The Grantee will take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race, religion, color, national origin, sex, sexual orientation, gender identity, age or disability. Such action shall include, but not be limited to the following; employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensations; and selection for training, including apprenticeship. The Grantee 7

8 agrees to post in conspicuous places, available to employees and applicants for employment, notices setting forth the provisions of this non-discrimination clause. 2. The Grantee will, in all solicitations or advertisements for employees placed by or on behalf of the Grantee, state that all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age or disability. 3. The Grantee will send to each labor union or representative of workers with which he has a collective bargaining agreement or other contract or understanding, a notice advising the said labor union or workers' representative of the Grantee's commitments under this section, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The Grantee will take such action with respect to any subcontract or purchase order as the administering agency may direct as a means of enforcing such provisions, including sanctions for noncompliance. 4. The Grantee will comply with all provisions of Executive Order No of September 24, 1965 as amended, and of the rules, regulations and relevant orders of the Secretary of Labor. 5. The Grantee will furnish all information and reports required by Executive Order No of September 24, 1965, as amended, and by the rules, regulations and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records and accounts by the administering agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations and orders. 6. In the event of the Grantee's noncompliance with the nondiscrimination clauses of this contract or with any of the said rules, regulations or orders, this contract may be cancelled, terminated or suspended in whole or in part and the Grantee may be declared ineligible for further government contracts or federally-assisted construction contracts in accordance with procedures authorized in Executive Order No of September 24, 1965, as amended, and such other sanctions may be imposed and remedies invoked as provided in or as otherwise provided by law. 7. The Grantee will include the provisions of paragraphs (1) through (7) of section 202 of Executive Order in every subcontract or purchase order unless exempted by rules, regulations or orders of the Secretary of Labor, issued pursuant to section 204 of Executive Order No of September 24, 1965, as amended, so that such provisions will be binding upon each subgrantee or vendor. The Grantee will take such action with respect to any subcontract or purchase order as the administering agency may direct as a means of enforcing such provisions including sanctions for noncompliance; provided, however, that in the event a Grantee becomes involved in, or is threatened with, litigation with a subgrantee or vendor as a result of such direction by the agency, the Grantee may request the United States to enter into such litigation to protect the interests of the United States. 21. The Grantor and the Grantee agree that this writing is a complete statement of the agreement and supersedes any prior terms, representations, or agreements whether made orally or in writing. 8

9 Please continue to the next pages to completely fill out score rubrics, the affidavit (which must be signed and notarized), the Form W-9, and information samples requested for your completed application. Incomplete applications will not be process and no reimbursements will be given until total application packet is received. Restaurant Name: Address: Phone: Contact: Fax: CATEGORY Memberships Promotion of Kentucky Proud Purchasing Menu development 5 You are a member of at least 3 other professional Culinary/Food organizations such as: KY Restaurant Association, ACI, Slow Foods Int., Community Food Alliance, KY Good Foods Coop, etc. You use the Kentucky Proud Logo on or achieve ALL of the following: 1) Your advertising; 2) Menus; 3) You highlight farmers products that you use in your establishment; 4) Your staff is trained as to what local farm products are used; 5) Your staff knows what the Kentucky Proud program is; 6) You promote products at professional meetings. You purchase Kentucky Proud products through ALL of the following: 1) You purchase direct from farmers; 2) at Farmers' Markets; 3) You use vendors that carry Kentucky Proud products; 4) You use products made in Kentucky that are Kentucky Proud. Your menu consists of over 75% Kentucky Proud products. 3 You are a member of at least 2 other professional Culinary/Food organizations such as: KY Restaurant Association ACI, Slow Foods Int., Community Food Alliance, KY Good Foods Coop, etc. You use Kentucky Proud Logo on or achieve 4 of the following: 1) Your advertising; 2) Menus; 3) You highlight farmers products that you use in your establishment; 4) Your staff is trained as to what local farm products are used; 5) Your staff knows what the Kentucky Proud program is; 6) You promote products at professional meetings. You purchase Kentucky Proud products through 3 of the following: 1) You purchase direct from farmers; 2) at Farmers' Markets; 3) You use vendors that carry Kentucky Proud products; 4) You use products made in Kentucky that are Kentucky Proud. Your menu consists of over 60% Kentucky Proud products. 2 You are a member of at least 1 other professional Culinary/Food organizations such as: KY Restaurant Association, ACI, Slow Foods Int., Community Food Alliance, KY Good Foods Coop, etc. You use Kentucky Proud Logo on or achieve 3 of the following: 1) Your advertising; 2) Menus; 3) You highlight farmers products that you use in your establishment; 4) Your staff is trained as to what local farm products are used; 5) Your staff knows what the Kentucky Proud program is; 6) You promote products at professional meetings. You purchase Kentucky Proud products through 2 the following: 1) You purchase direct from farmers; 2) at Farmers' Markets; 3) You use vendors that carry Kentucky Proud products; 4) You use products made in Kentucky that are Kentucky Proud. Your menu consists of over 40% Kentucky Proud products. 1 point You MUST be a member of and know what the program is You use the Logo in some of your advertising and your menus You purchase products. Your menu consists of some Kentucky Proud products by request of event. Total 9

10 CATEGORY point Total Farmer Impact Purchasing Power You purchase products from over 20 Kentucky Proud farmers. You spend over 75 % of your food budget per year on direct Kentucky farm products. You purchase products from over 10 Kentucky Proud farmers. You spend over 50% of your food budget per year on direct Kentucky farm products. You purchase products from over 5 Kentucky Proud farmers. You spend over 25% of your food budget per year on direct Kentucky farm products. You purchase products from farmers. You spend over 10% of your food budget per year on direct Kentucky farm products. Past support You have never received KDA/ funding. You have received KDA/ funding once not exceeding $2,500. You have received KDA/ funding in the past not exceeding $5,000. You have received KDA/Kentucky Proud funding in the past exceeding $10,000. Restaurant Input: (feel free to attach sheets or pictures and other supporting documents) Staff Input Date Created: 12/03/14 AGC Total Score: Reimbursement is now based on a percentage determined by rubrics scoring. With a score of Reimbursement Rate = 100% of 20% = 20% = 90% of 20% = 18% = 80% of 20% = 16% = 70% of 20% = 14% = 60% of 20% = 12% Up to 9 = 50% of 20% = 10% To determine your reimbursement rate, calculate your rubrics score and look at the corresponding percentage rate. This is the percentage for which you are eligible of the maximum 20 % reimbursement. Next, multiply the amount of eligible expenses by the corresponding reimbursement rate. For example, if you submit $60,000 worth of eligible purchases/receipts and score 30-35, you are eligible for the full 20% reimbursement and will receive the maximum reimbursement amount of $12,000. If you submit $60,000, but only score 20-24, your reimbursement rate is 16%; and you will receive $9,600 in reimbursement. New Requirements! Please submit samples of your promotional effort. (Pictures, menus, and/or advertising etc.) Please submit evidence of your percentage use of products on your menu. 10

11 Please list products you have purchased, the suppliers, and approximate yearly amounts. (We understand this will change seasonally, but we would like to see producers and products that you have purchased in the past and are planning to purchase. Products Suppliers Amounts Please include another copy of this sheet if needed. 11

12 Solicitation/Contract #: REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS PAGE 1 OF 2 FOR BIDS AND CONTRACTS IN GENERAL: I. Each bidder or offeror swears and affirms under penalty of perjury, that: a. In accordance with KRS 45A.110 and KRS 45A.115, neither the bidder or offeror as defined in KRS 45A.070(6), nor the entity which he/she represents, has knowingly violated any provisions of the campaign finance laws of the Commonwealth of Kentucky; and the award of a contract to the bidder or offeror or the entity which he/she represents will not violate any provisions of the campaign finance laws of the Commonwealth. b. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and all subcontractors therein, are aware of the requirements and penalties outlined in KRS 45A.485; have properly disclosed all information required by this statute; and will continue to comply with such requirements for the duration of any contract awarded. c. The bidder or offeror swears and affirms under penalty of perjury that, to the extent required by Kentucky law, the entity bidding, and its affiliates, are duly registered with the Kentucky Department of Revenue to collect and remit the sales and use tax imposed by KRS Chapter 139, and will remain registered for the duration of any contract awarded. d. The bidder or offeror swears and affirms under penalty of perjury that the entity bidding is not delinquent on any state taxes or fees owed to the Commonwealth of Kentucky and will remain in good standing for the duration of any contract awarded. FOR NON-BID CONTRACTS (I.E. SOLE-SOURCE; NOT-PRACTICAL OR FEASIBLE TO BID; OR EMERGENCY CONTRACTS, ETC): II. Each contractor further swears and affirms under penalty of perjury, that: a. In accordance with KRS , and if this is a non-bid contract, neither the contractor, nor any member of his/her immediate family having an interest of 10% or more in any business entity involved in the performance of any contract awarded, have contributed more than the amount specified in KRS to the campaign of the gubernatorial slate elected in the election last preceding the date of contract award. b. In accordance with KRS (1) and (2), and if this is a non-bid contract, neither the contractor, nor officers or employees of the contractor or any entity affiliated with the contractor, nor the spouses of officers or employees of the contractor or any entity affiliated with the contractor, have knowingly contributed more than $5,000 in aggregate to the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract award. 12

13 Solicitation/Contract #: REQUIRED AFFIDAVIT FOR BIDDERS, OFFERORS AND CONTRACTORS PAGE 1 OF 2 c. In accordance with KRS (3) and (4), and if this is a non-bid contract, to the best of his/her knowledge, neither the contractor, nor any member of his/her immediate family, his/her employer, or his/her employees, or any entity affiliated with any of these entities or individuals, have directly solicited contributions in excess of $30,000 in the aggregate for the campaign of a candidate elected in the election last preceding the date of contract award that has jurisdiction over this contract. As a duly authorized representative for the bidder, offeror, or contractor, I have fully informed myself regarding the accuracy of all statements made in this affidavit, and acknowledge that the Commonwealth is reasonably relying upon these statements, in making a decision for contract award and any failure to accurately disclose such information may result in contract termination, repayment of funds and other available remedies under law. Signature Printed Name Title Date Company Name Address Subscribed and sworn to before me by (Affiant) (Title) of (Company Name) this day of, 20. Notary Public [seal of notary] My commission expires: 13

14 Kentucky Department of Agriculture Restaurant Rewards Reimbursement Request Form 111 Corporate Drive Frankfort, KY Phone (502) Fax (502) Date: State Vendor ID#: VC Attach a copy of all food receipts to this form. In order to confirm product edibility, all producers or Product suppliers must be listed. Kentucky Proud Certificate Number: Restaurant Name: Contact Name: Address: CITY: STATE: ZIP: Phone: ( ) - Cell Phone: ( ) - Fax: ( ) - Address: PURCHASE Date ITEM Description Quantity Total Expense $ Producer/Contact Information (for eligibility confirmation) Please attach a separate sheet for additional product listings and copies of all invoices. Return completed form, along with copies of all invoices to: By Mail Kentucky Department of Agriculture Attn: Restaurant Rewards 111 Corporate Drive Frankfort, KY By Fax: (502) (For Office Use Only) Audited By: DATE: Approved By: DATE: Approved By: DATE: TOTAL REIMBURSEMENT: $ BY: DATE: Questions? Contact Angela Caporelli by phone (502) or angela.caporelli@ky.gov.