17 Offering Entity Acknowledgement Form Franklin County OH 36C10F25R0057.pdf

OFFERING ENTITY ACKNOWLEDGEMENT FORM

Solicitation Information RLP No.:

City, ST – Facility:

Offer Due Date/Time:

The Offeror attests that the information provided below is accurate and complete and understands that it will be used as a basis for evaluation under the referenced RLP. Failure to provide the required information may render the proposal non-responsive.

A. Offeror Information

Offering Entity Legal Name:

Address:

UEI Number:

Tax Identification Number:

Authorized Official Name:

Authorized Official Title:

Authorized Official Phone:

Authorized Official Email:

By checking this box, the Authorized Official confirms they are identified in the Entity’s governing documents submitted in the proposal.

B. Offeror Entity / Prime Contractor Status

Check applicable Socio-Economic status:

SDVOSB VOSB Small Business Other Than SB Joint Venture

Offering Entity is currently registered and active in SAM under NAICS 531120 Offering Entity is currently verified in VetCert (check if applicable, otherwise, leave blank)

C. Offering Entity Ownership / Relationship to Property (check all that apply):

Fee Simple Owner of the Property Ground Lessor / Master Lessee Developer with Site Control (e.g., purchase contract, ground lease, option) Agent or Other Entity Authorized to Submit an Offer on behalf of the Owner If “Agent or Other Entity” is checked, the Offeror has provided evidence of ownership or control of the Building or site and written authorization from the ownership entity to submit an offer on its behalf (check if applicable, otherwise, leave blank).

D. Signature

By signing below, the undersigned attests that they are duly authorized to bind the Offering Entity and that all information provided herein is complete and accurate.

Offering Entity Authorized Official Printed Name:

Offering Entity Authorized Official Title:

Offering Entity Authorized Official Signature:

Date: