00 45 60 Steel Origin Certification.pdf

00 45 60 Steel Origin Certification

Steel Products Procurement Act

73 P.S. §§1881 - 1887, as amended

4 PA Code Chapter 67a

This form must be executed by the Fabricator/Manufacturer of the steel product and submitted to the Owner, Capital Region Water. This executed Steel Origin Certification will be considered as evidence that the steel product listed on Line 7 below is produced domestically.

The Fabricator/Manufacturer (Firm) shall complete this Certification in its entirety.

1. Firm name: __________________________________________________________________

2. Address: ____________________________________________________________________

3. Firm contact person: ___________________________________________________________

4. Firm phone number: ___________________________________________________________

5. Firm Federal Employer ID No.: ___________________________________________________

6. Firm web site address (if available): _______________________________________________

7. Steel Product: ________________________________________________________________

8. Model (if applicable): __________________________________________________________

CERTIFICATION: I, the undersigned officer of the Fabricator/Manufacturer, do certify that our Firm assembles/fabricates the components to the steel products listed on Line 7 and Line 8 (if applicable), and that all steel components therein are comprised of steel that is melted and/or fabricated in the

United States. I understand that, by signing this document, I certify that I have received assurances from the suppliers/manufacturers of the components that said components do not contain foreign manufactured steel. I further understand that this document is subject to the provisions of the

Unsworn Falsification to Authorities Act (18 P.S. §4904). I also understand that I am subject to the provisions of the Steel Products Procurement Act (73 P.S. §1881, et seq.) which provides penalties including, but not limited to, debarment from supplying any products for public works projects or any public agency for a period of five (5) years for violations therein. I agree to provide documentation supporting these facts if requested. The Owner reserves the right to pursue any action deemed necessary to protect its interest and ensure compliance with the laws of the Commonwealth.

WITNESS:

Name: _____________________________

(Print Name)

Title, Office or Position at the Firm

(Seal)

Name: ______________________________

(Print Name)

Title, Office or Position at the Firm