3-D-DFCM Termination or Debarment Certification Form, 5.8.25.docx

This is a Termination or Debarment Certification Form required by the State of Utah Division of Facilities Construction and Management (DFCM) for the USCF Water Pump Station Modification & Fire Storage Tank project. The form certifies that the contractor is not currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from soliciting work by any government agency. The certification also confirms that the contractor has not been terminated during performance of a previous contract or withdrawn from a contract to avoid termination. The form requires the contractor's signature, name, title, and date, with a corresponding section for an authorized representative to provide the same information.

If the contractor cannot certify to the above statement, the form requires a detailed explanation of the circumstances on a separate section that also requires signature, name, title, and date. This certification is a standard compliance requirement for the construction project with an estimated cost of $2,500,000.00 and must be completed and submitted as part of the proposal response process.