3-Attachment F - Combined Corporate Accountability and Workforce Safety Affidavit.pdf

1 Version 3/21/2024

COMBINED AFFIDAVIT

OF

WORKFORCE SAFETY &

CORPORATE ACCOUNTABILITY

Contract No:

I am , and state under oath:

I am the _____________________ of ____________________________________________

(“Contractor”), and represent that I am authorized to execute this affidavit on behalf of the

Contractor, and its owners, directors, and officers. I am the Chief Executive Officer, or authorized designee, and attest to the Contractor’s compliance with the following requirements:

A. I represent that the following statements regarding Workforce Safety are true:

(1) All employees and subcontractors handling or interacting with hazardous materials have been properly trained, through completion in hazardous materials awareness training; or participation and completion in the requisite awareness training program compliant with state and federal guidelines; and

(2) All employees and subcontractors providing craft labor have at a minimum completed the OSHA 10-hour construction training course for safety established by the U.S. Department of Labor, Occupational Safety and Health Administration.

B. I also represent that the following statements regarding Corporate Accountability are true:

(1) The Contractor and its employees have the required licenses, registrations, and certificates required to perform the work as stated in the solicitation; and

(2) The Contractor has not had any licenses, registrations, or certificates which are required for the performance of the contract revoked in the past five (5) years; and

(3) The Contractor has not been debarred by any federal, state or local governmental agency or authority in the past three (3) years.

I understand and acknowledge that the above representations are material and important and will be relied upon by the City of Detroit in determining the Contractor’s eligibility for this contract(s)/purchase order(s). I understand and acknowledge, and the Contractor understands and acknowledges that the City of Detroit will treat any misstatement or false representation in this affidavit as a fraudulent activity relating to the eligibility of award for this contract(s)/purchase order(s) under City Ordinance 17-5-12 (g)(1), with intent to defraud the City of Detroit pursuant to MCL 750.249.

Officer Title

Name

Organization Name

2 Version 3/21/2024

**This Document MUST be Notarized**

Complete the section below

Printed Name & Title of Authorized Representative:

Signature of Authorized Representative:

Date:

This document was acknowledged, subscribed, and sworn before me___________ day of

__________, _______, by ____________________________,the ___________________________ of ______________________________.

Signature of Notary:

Printed Name of Seal of Notary:

My Commission Expires: / /

THIS SECTION IS FOR OCP USE ONLY:

Affidavits Received & Clearance Date:

Date

Year Name of Authorized AgentMonth Officer Title

Name of Organization