2-B-DFCM Termination Debarment Certification Form 8.9.2024.pdf

This is a Termination or Debarment Certification Form issued by the State of Utah Department of Public Licensing (DOPL) for the Division of Facilities Construction and Management (DFCM) Design-Build project for the Logan Fish Hatchery Residence. The form requires the bidding firm and its principals to certify that they are not currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from soliciting work by any government agency. Additionally, the certification confirms that neither the firm nor its principals have been terminated during the performance of a contract or withdrawn from a contract to avoid termination. The form provides space for the firm name, applicable licensing number, signature, name, title, and date from an authorized representative.

If a firm cannot certify compliance with the debarment and termination requirements, the form requires submission of an explanation detailing the circumstances. The form structure allows for multiple signatory entries and includes fields for DOPL documentation. This certification is a standard pre-award requirement for state of Utah construction projects and must be completed and submitted as part of the proposal package for the Design-Build team competing for the Logan Fish Hatchery Residence project, which has a maximum budget of $500,000.