2-26-114 Disclosure-Debarment Required Form.pdf
PDF 68 KB Posted
- Solicitation number
- 26-114
- Issued by
- Fulton County, Georgia
About this file
This is a Bidder's Disclosures and Certifications form required by the City of Alpharetta for RFP 26-114, the Alpha Loop Design project along Northwinds Parkway, Haynes Bridge Road, and Morrison Parkway in Georgia. The form mandates that bidders disclose any conflicts of interest, relationships with city elected officials or employees, and campaign contributions made within the past two years. Bidders must certify their non-debarment status and confirm they have not been suspended, proposed for debarment, or declared ineligible by any federal, state, or local entity. The form requires disclosure of any criminal convictions or civil judgments rendered within the three-year period preceding the bid submission for offenses including fraud, antitrust violations, embezzlement, theft, forgery, bribery, falsification of records, false statements, tax evasion, or receiving stolen property. Additionally, bidders must certify that no contracts have been terminated for default by any public agency within the three-year period preceding the offer.
The certification requires an authorized officer to attest under oath that the bid response is accurate, truthful, and submitted without prior understanding or agreement with competing bidders, and that the firm complies with all state and federal equal opportunity and non-discrimination requirements. Bidders must certify that employees will not engage in business ventures with city employees or consulting engineers, nor provide gifts, gratuities, favors, or items of value to city department employees. The form must be notarized and signed by an authorized officer or agent of the bidding firm, with the notary's commission expiration date and stamp required. All contractors submitting responses for the Alpha Loop Design project must complete and submit this disclosure and certification form as a condition of bid responsiveness.
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Text version
BIDDER’S DISCLOSURES AND CERTIFICATIONS
PROCUREMENT NUMBER & TITLE:
DISCLOSURE FORM AND CERTIFICATION OF NON-COLLUSION
Bidder must disclose any possible conflict of interest and/or any relationship that exists between any principal or employee of your corporation/firm/team/organization and with any City elected official and/or employee. Relationship may be financial, personal, or family or may be in the form of campaign contributions to elected officials. State whether Relationship DOES or DOES NOT exist. Failure to disclose or to submit this completed form may result in response being declared non-responsive and will not be considered further.
Check applicable box. Use additional forms if needed:
No known relationship exists
Yes, Relationship does exist
If this box checked, include the name and position of the City Official to whom a campaign contribution was made or official/employee relationship.
Use a separate form for each official to whom a contribution has been made within the past two (2) years or for additional official/employee relationships.
City Elected Official and/or Employee Name and position
Contribution Amount/Value (if any) Contribution Date and Description
List other Relationship if not contribution
CERTIFICATION REGARDING DEBARMENT, SUSPENSION. PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS The Contractor certifies to the best of its knowledge and belief that neither it nor any of its principals:
1. are presently debarred, suspended, proposed for debarment, or declared ineligible from submitting bids or proposals by any federal, state or local entity, department or agency;
2. have within a three-year period preceding this bid/offer, been convicted or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performance of a public (Federal, state or local) contract or subcontract;
violation of Federal or state antitrust statues relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statement, tax evasion, or receiving stolen property;
3. are presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in paragraph 2 of this certification;
4. have within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal, state or local public agency.
By signing this form, I certify that:
• As an officer of this firm, or per the attached letter of authorization, I am duly authorized to certify the information provided herein is accurate and true; and my firm shall comply with all State and Federal Equal Opportunity and Non-Discrimination requirements and conditions of employment.
• That the firm’s response is made without prior understanding, agreement, or connection with any corporation, firm, team, organization, or person submitting a response for the same materials, supplies, equipment, opportunity, or services and is in all respects fair and without collusion or fraud. My firm understands and agrees that bid/proposal collusion is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards;
• Employees of this company or employees of any company supplying material or subcontracting to do work on this Contract will not engage in business ventures with employees of the CITY or Consulting Engineers nor shall they provide gifts, gratuities, favors, entertainment, loans or other items of value to employees of this Department, and
• That the provisions of the Official Code of Georgia Annotated, Sections 45-10-20 et seq. have not been violated and will not be violated in any respect. O.C.G.A.
45-10-20 through 45-10-28 provide that it is unlawful for a City elected official or employee to transact business with the City by which that person is employed for himself, on behalf of a business in which the employee or his/her spouse or dependents has a substantial interest, or on behalf of anyone as agent, broker, dealer, or representative.
________________________________________________________ Subscribed and sworn before me on this the Company Name
________________________________________________________ __________day of ____________________________, 20_______ Signature of Authorized Officer or Agent
Date Notary Public
Printed Name & Title of Authorized Officer or Agent My Commission Expires
Company Address
(Notary Stamp)
| Contribution AmountValue if any: |
| Contribution Date and Description: |
| List other Relationship if not contribution: |
| Company Name: |
| Date: |
| Company Address: |
| PROCUREMENT NUMBER and TITLE: RFP 26-114, Alpha Loop Design on Northwinds Pkwy, Haynes Bridge Rd, Morrison Pkwy |
| No relationship: Off |
| Yes Relationship: Off |
| Elected Official and/or Employee Name and Position: |
| Name and Title of Signer: |
| Day: |
| Month: |
| Year: |
| Date Commission Expires: |
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