3-C-DFCM Termination Debarment Certification Form 8.9.2024.pdf
PDF 667 KB Posted
- Solicitation number
- CS27011
- Issued by
- Utah
About this file
This is a Termination Debarment Certification Form issued by the State of Utah's Division of Facilities Construction and Management (DFCM) related to a construction consultant services solicitation for the Department of Transportation. The project involves repairing and replacing five pump houses to meet UDOT's operational needs, with an associated construction budget of $3,242,656.00. The form serves as a certification document that prospective bidders and contractors must complete and submit as part of their proposal requirements, confirming their debarment status and eligibility to participate in state contracting opportunities.
The certification form requires signatories to attest that they and their principals are not currently debarred, suspended, or otherwise ineligible to receive government contracts. This documentation is a mandatory compliance requirement under state procurement regulations and must be executed by authorized representatives of proposing firms or individuals. The form dated August 9, 2024, ensures that all parties bidding on the consultant services and subsequent construction work meet the requisite eligibility standards and possess no disqualifying factors that would prevent them from contracting with the State of Utah.
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Text version
DFCM Termination or Debarment Certification Form, Revised 8.9.2024
Termination or Debarment Certification Form
Firm Name:
State of Utah Department of Public Licensing Number, if applicable:
The signature below certifies that the referenced firm nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or are voluntarily excluded from soliciting work by any government agency. This form also certifies that neither they nor their principals have been terminated during the performance of a contract or withdrew from a contract to avoid termination.
Signature:
Name:
Title:
Date:
If the firm cannot certify to the statement above, please provide an explanation of the circumstances below.
Signature:
Name:
Title:
Date:
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Explanation:
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