3-C-DFCM Termination Debarment Certification Form 8.9.2024.pdf
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- Solicitation number
- MP27007
- Issued by
- Utah
About this file
This is a Termination or Debarment Certification Form issued by the State of Utah Department of Public Licensing (DFCM), revised August 9, 2024, for use in connection with a Programming & Design services solicitation for Utah Valley University's Student Athletic Center project. The form requires certified firms or individuals to affirm that neither they nor their principals are currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from soliciting work by any government agency. The certification also confirms that the firm and its principals have not been terminated during contract performance or withdrawn from a contract to avoid termination. The form provides space for the firm name, signature, name, title, and date of the authorized representative, with an additional section for explanations should the firm be unable to certify to the stated requirements.
The form serves as a compliance document for the Division of Facilities Construction and Management's request for proposal related to the repair and remodel of the SAELA building for Utah Valley University's Athletics Department, which carries a construction budget of $3,100,000. This certification is a standard prerequisite requirement for contractors and consultants bidding on state of Utah construction and professional services projects and must be completed and submitted as part of the proposal package.
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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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