1-12. Submittal Form- Debarment or Suspension, Conflicts, Tax Lien, Responsiveness.docx
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- Solicitation number
- UDOT260065MP
- Issued by
- Utah
About this file
This is a Submittal Form for Certifications addressing debarment, conflicts of interest, tax liens, and other information relevant to vendor responsiveness for the Utah Department of Transportation's Request for Proposals for Toll Back Office System and Customer Service Center Support. The form requires vendors to certify their eligibility and compliance status across four key areas: whether the vendor has been or is currently debarred, suspended, proposed for debarment, or declared ineligible by any government entity; whether any conflicts of interest or potential conflicts of interest exist that could arise during contract performance; whether the vendor has outstanding tax liens in the State of Utah; and whether any other information exists that is not disclosed in the proposal that could impact the State's determination of vendor responsiveness or suitability for contract award.
The form structure provides vendors with binary yes-or-no response options for each certification category, with a requirement that vendors provide detailed written explanations for any affirmative responses. Vendors must disclose circumstances related to debarment actions, conflicts of interest, outstanding tax liens, and other material information such as pending legal actions, significant personnel changes, loss of major contracts, or alleged violations of federal, state, or local regulations. This certification document serves as a critical responsiveness requirement for the single contract award anticipated from this solicitation and ensures that only qualified, eligible vendors without disqualifying circumstances can be considered for the toll back office system and customer service center support contract.
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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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