3-C-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 firms seeking to provide services on Division of Facilities Construction and Management (DFCM) projects. The form certifies that the referenced firm and its principals are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from soliciting work by any government agency. The certification also confirms that neither the firm nor its principals have been terminated during the performance of a contract or withdrew from a contract to avoid termination. Firms must complete and sign the form to verify their eligibility to work on state projects, with signature lines for company representatives to confirm their status as of the certification date.

If a firm cannot certify to the stated requirements, it must provide a detailed explanation of the circumstances below the certification statement, accompanied by signatures of authorized personnel. This form is a mandatory compliance document for all firms, including special inspections contractors and material testing labs, that wish to be considered for DFCM projects, such as the Loa Fish Hatchery construction project with an estimated inspections budget of $280,000. The form serves as a prerequisite qualification document that must be submitted as part of the bidding process to demonstrate the firm's integrity and compliance with state and federal debarment regulations.