17-Anti-Collusion-and-Debarment-Certification-12-15-11.pdf

12/15/11 Page 1 of 2

SPONSOR

SUPPLEMENT TO PROPOSAL

ANTI-COLLUSION AND DEBARMENT CERTIFICATION

FAILURE TO EXECUTE AND SUBMIT THIS CERTIFICATION SHALL RENDER THIS BID

NONRESPONSIVE AND NOT ELIGIBLE FOR AWARD CONSIDERATION.

As a condition precedent to the acceptance of the bidding document for this project, the bidder shall file this Affidavit executed by, or on behalf of the person, firm, association, or corporation submitting the bid.

The original of this Affidavit shall be filed with the SPONSOR at the time proposals are submitted.

A F F I D A V I T

I hereby certify, under penalty of perjury under the laws of the United States and/or the State of Arkansas, that the bidder listed below has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with the submitted bid for this project, is not presently barred from bidding in any other jurisdiction as a result of any collusion or any other action in restraint of free competition, and that the foregoing is true and correct.

Further, that except as noted below, the bidder, or any person associated therewith in the capacity of owner, partner, director, officer, principal investigator, project director, manager, auditor, or any position involving the administration of Federal funds:

a. is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any Federal agency;

b. has not been suspended, debarred, voluntarily excluded or determined ineligible by any Federal agency within the past 3 years;

c. does not have a proposed debarment pending; and

d. has not been indicted, convicted, or had an adverse civil judgment rendered by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past 3 years.

12/15/11 Page 2 of 2

SPONSOR

SUPPLEMENT TO PROPOSAL

ANTI-COLLUSION AND DEBARMENT CERTIFICATION

FAILURE TO EXECUTE AND SUBMIT THIS CERTIFICATION SHALL RENDER THIS BID

NONRESPONSIVE AND NOT ELIGIBLE FOR AWARD CONSIDERATION.

EXCEPTIONS:

APPLIED TO INITIATING AGENCY DATES OF ACTION

Exceptions will not necessarily result in denial of award, but will be considered in determining bidder responsibility. Providing false information may result in criminal prosecution or administrative sanctions.

Job No.

(Name of Bidder) F.A.P. No.

(Signature)

(Date Executed) (Title of Person Signing)

The following Notary Public certification is OPTIONAL and may or may not be completed at the contractor's discretion.

State of ___________________________ ) County of ___________________________ )ss.

_______________________________________, being duly sworn, deposes and says that he is

_______________________________________ of __________________________________________ (Title) (Name of Bidder) and that the above statements are true and correct.

Subscribed and Sworn to before me this _____ day of ____________________, 20_____.

My commission expires:______________________________________

(Notary Public)

(NOTARY SEAL)

AFFIDAVIT