4-SAM Certification.pdf
PDF 74 KB Posted
- Attached to
- Loan Servicing
- Solicitation number
- RFP260113
- Issued by
- Bath County, Kentucky
About this file
This document is a Certification Regarding Debarment, Suspension and Other Responsibility form. The form requires a business entity to certify its compliance with federal debarment regulations by marking one of two options: either affirming that the business and its principals are not currently debarred, suspended, or excluded from federal transactions, or indicating an inability to make such a certification with an attached explanation. The form requires the signature, printed name, title, and date from an authorized representative of the business entity.
The certification serves as a standard federal procurement requirement to ensure that businesses seeking to participate in government transactions have not been previously prohibited from doing so due to past performance or legal issues. By completing this document, the business entity is providing a formal declaration of its eligibility to engage in federal contracting processes, with legal implications for false statements. The form is intentionally straightforward, allowing for a simple, direct attestation of the business's standing with federal agencies.
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Text version
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY
Business Entity Name
PLEASE MARK ONE:
___ I hereby certify that, as of ________________, to the best of my knowledge and belief, ________________________________________, and its principals are not presently debarred, suspended, proposed for debarment declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.
___ I am unable to certify to any of the statements in this certification and an explanation is hereby attached.
Signature of Authorized Representative
Printed Name of Authorized Representative
Title, Role or Capacity of Authorized Representative
Date
| Printed Name of Authorized Representative: |
| Title Role or Capacity of Authorized Representative: |
| Check Box1: Off |
| Check Box2: Off |
| Date 1: |
| Date 2: |
| Business Entity Name: |
File details come from the government source that posted it. Updated .