05. Appendix D - Iran Free Procurement Certification Form.pdf
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- Solicitation number
- 6100066636
- Issued by
- Pennsylvania
About this file
This is an Iran Free Procurement Certification Form document issued by the Commonwealth of Pennsylvania's Department of General Services (DGS) in accordance with Pennsylvania's Procurement Code Sections 3501-3506. The form applies to vendors seeking contracts worth $1,000,000 or more with Commonwealth entities for Medical Supplies, Medical Equipment, Nutritional Supplements, and Incontinent Supplies across state healthcare facilities. Vendors must submit the completed certification as part of their bid submission through the PA Supplier Portal at www.pasupplierportal.state.pa.us, with all questions due by October 9, 2026, by end of business day to jahildebra@pa.gov.
The certification requires vendors to declare one of two options: either certify that they are not on the current DGS list of persons engaged in investment activities in Iran and are therefore eligible to contract with the Commonwealth, or demonstrate receipt of a written exemption from DGS pursuant to Procurement Code Section 3503(e) for case-by-case exceptions. Pennsylvania law establishes significant penalties for false certifications, including civil penalties equal to the greater of $250,000 or twice the contract amount, contract termination, and three-year ineligibility to bid on future Commonwealth contracts. Authorized company officials must execute the certification with their printed name, title, and date.
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BOP-1701
Published: 1/26/2017
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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