4-SAM Certification.pdf

This is a Certification Regarding Debarment, Suspension and Other Responsibility form required for state and local contract opportunities, though no specific agency or jurisdiction is identified in the document. The form serves as a mandatory certification that bidding entities and their principals are not currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in federal transactions. The document provides two checkbox options: one for certifying compliance with debarment requirements and another for entities unable to certify compliance, which requires an attached explanation.

The form requires completion by an authorized representative who must provide their signature, printed name, title or role, and date of certification. The business entity name must be filled in at the top of the form, and the certification date must be specified. This certification appears to be a standard requirement for contract submissions to ensure that only eligible entities participate in government contracting opportunities, serving as a pre-qualification screening tool for procurement processes.