1-07. Submittal Form- Debarment or Suspension, Conflicts, Tax Lien, Responsiveness.docx
DOCX document 17 KB Posted
- Solicitation number
- UDOT260178TM
- Issued by
- Utah
About this file
This is a Submittal Form for Certifications required by the Utah Department of Transportation (UDOT) for the St. George Utah Port of Entry Portable Restrooms and Servicing Invitation for Bid (IFB). The form requires vendors to certify their status regarding debarment, suspension, or ineligibility by any government agency; conflicts of interest that may arise during contract performance; outstanding tax liens in the State of Utah; and any other material information that could impact the state's determination of vendor responsiveness for contract award.
The certification form includes four primary sections with yes/no response options, each requiring vendors to provide detailed written explanations if they answer affirmatively to any question. Vendors must declare whether they have been debarred, suspended, proposed for debarment, or declared ineligible by any international, national, state, or local government department or agency. Additionally, vendors must disclose any actual or potential conflicts of interest; outstanding tax liens within Utah; and any other information including legal actions, personnel changes, loss of major contracts, or alleged violations of federal, state, or local regulations that could affect the state's assessment of vendor responsiveness. Submission of this completed certification form is mandatory for bid consideration under the Utah Procurement Code and Utah Administrative Code requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| 7-01. IFB General Bid Information.doc | DOC document | |
| 5-06. Submittal Form- Pricing.doc | DOC document | |
| 3-03. Submittal Form- Vendor Set Up Form.pdf | ||
| 6-05. Submittal Form- Attachment A- Agency Terms and Conditions- check boxes.docx | DOCX document | |
| 2-04. Submittal Form- Business Confidentiality- check fields.doc | DOC document | |
| 4-02. Scope of Work.doc | DOC document |
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Text version
Certifications- Debarment, Conflict of Interest, Outstanding Tax Lien, Other Information
1. DEBARMENT- Is vendor presently or has vendor ever been debarred, suspended, proposed for debarment, or declared ineligible by any government department or agency, whether international, national, state, or local? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I have not been debarred, suspended, proposed for debarment, or declared ineligible.
Yes, I am or have been debarred, suspended, proposed for debarment, or declared ineligible (see as follows):
2. CONFLICT OF INTEREST- Does Vendor have any conflict, or potential conflict of interest, that might arise during the contract? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have any Conflict or Potential Conflict of Interest.
Yes, I do have a Conflict or Potential Conflict of Interest (see as follows):
3. OUTSTANDING TAX LIEN- Does vendor have an outstanding tax lien in the State of Utah? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have an outstanding Tax Lien.
Yes, I do have an outstanding Tax Lien (see circumstances as follows):
4. OTHER INFORMATION- Does vendor have any information that is not already provided within its proposal that if known to the State would impact the State’s determination on vendor's responsiveness for a contract award (i.e., legal action, recent turn-over in major personnel, loss of a major contract, any alleged violations of federal, state or local regulations, etc.). Please see UCA 63G-6a-120 & 902. If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have any Other Information.
Yes, I do have Other Information (see as follows):
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