04 Appendix B - Iran Free Procurement Certification Form.pdf
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- Attached to
- Fish Treatment Chemicals
- Solicitation number
- 6100054186
- Issued by
- Centre County, Terre Hill Borough, Pennsylvania
About this file
This document is the Iran Free Procurement Certification Form required for vendors seeking to contract with the Commonwealth of Pennsylvania for goods or services worth at least $1,000,000 or more. The form requires the vendor to certify that it is not on the current list of persons engaged in investment activities in Iran created by the Pennsylvania Department of General Services (DGS), or to demonstrate that it has received an exception from the certification requirement pursuant to the Procurement Code. Vendors must complete one of the two provided options on the form, either certifying their eligibility or providing documentation of an exemption approval, and the form must be signed by an authorized representative.
The form outlines the penalties for providing false certifications, including civil penalties, contract termination, and three-year ineligibility to bid on contracts. It also notes that DGS may, on a case-by-case basis, permit a vendor engaged in investment activities in Iran to enter into a contract upon receiving a written exemption.
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IRAN FREE PROCUREMENT CERTIFICATION FORM
(Pennsylvania’s Procurement Code Sections 3501-3506, 62 Pa.C.S. §§ 3501-3506)
To be eligible for an award of a contract with a Commonwealth entity for goods or services worth at least $1,000,000 or more, a vendor must either: a) certify it is not on the current list of persons engaged in investment activities in Iran created by the Pennsylvania Department of General Services (“DGS”) pursuant to Section 3503 of the Procurement Code and is eligible to contract with the Commonwealth under Sections 3501-3506 of the Procurement Code; or b) demonstrate it has received an exception from the certification requirement for that solicitation or contract pursuant to Section 3503(e).
To comply with this requirement, please insert your vendor or financial institution name and complete one of the options below. Please note: Pennsylvania law establishes penalties for providing false certifications, including civil penalties equal to the greater of $250,000 or twice the amount of the contract for which the false certification was made; contract termination; and three-year ineligibility to bid on contracts. (Section 3503 of the Procurement Code.)
OPTION #1 - CERTIFICATION
I, the official named below, certify I am duly authorized to execute this certification on behalf of the vendor/financial institution identified below, and the vendor/financial institution identified below is not on the current list of persons engaged in investment activities in Iran created by DGS and is eligible to contract with the Commonwealth of Pennsylvania Sections 3501-3506 of the Procurement Code.
Vendor Name/Financial Institution (Printed)
By (Authorized Signature)
Printed Name and Title of Person Signing Date Executed
OPTION #2 – EXEMPTION
Pursuant to Procurement Code Section 3503(e), DGS may permit a vendor/financial institution engaged in investment activities in Iran, on a case-by-case basis, to enter into a contract for goods and services.
If you have obtained a written exemption from the certification requirement, please fill out the information below, and attach the written documentation demonstrating the exemption approval.
Vendor Name/Financial Institution (Printed)
By (Authorized Signature)
Printed Name and Title of Person Signing Date Executed
| IRAN FREE PROCUREMENT CERTIFICATION FORM |
| (Pennsylvania’s Procurement Code Sections 3501-3506, 62 Pa.C.S. §§ 3501-3506) |
| OPTION #1 - CERTIFICATION |
| OPTION #2 – EXEMPTION |
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