47_019 _ Exhibit H _ Debarment and Suspension.pdf
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- Solicitation number
- PE-77129-NONST-2027-000000079
- Issued by
- Hall County, Georgia
About this file
This is a Debarment and Suspension Certification Form issued by Hall County Government's Financial Services Purchasing Division for RFQ/P# 47-019, which concerns a complete roof replacement project at the Hall County Jail in Gainesville, Georgia. The form serves as a mandatory compliance document that all bidders must complete and submit with their proposals. The certification requires respondents to attest to their eligibility status regarding federal, state, and local contract participation by confirming they are not debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions.
The certification encompasses four primary representations: (1) that the respondent and its principals are not presently debarred or suspended from federal transactions; (2) that they have not been convicted of fraud or criminal offenses related to public transactions within the three-year period preceding the proposal; (3) that they are not currently indicted or criminally or civilly charged by any governmental entity for qualifying offenses; and (4) that they have not had public transactions terminated for cause or default within the three-year period preceding the application. Respondents who cannot certify any of these statements are required to attach a written explanation to their proposal. The form requires the company name, authorized signature, printed name and title of the signatory, and the date of certification.
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Text version
Hall County Government
FINANCIAL SERVICES
PURCHASING DIVISION
POST OFFICE DRAWER 1435
GAINESVILLE, GA 30503
t: 770.535.8270 | f: 770.531.6711
FINANCIAL SERVICES DIRECTOR
Taylor Samples, CPA
ASSISTANT FINANCE DIRECTOR
Elizabeth White
PURCHASING MANAGER
Andrew Youngblood
EXHIBIT H – DEBARMENT AND
SUSPENSION CERTIFICATION FORM
Bidders must complete and return this form with their bid.
The undersigned Respondent certifies, to the best of his or her knowledge and belief, that it and its principals (as defined 2 CFR
200.214 and 2 CFR 180.300):
1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;
2. Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction;
3. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in this certification; and
4. Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local) terminated for cause or default.
Where the Respondent is unable to certify any of the statements in this certification, such Respondent shall attach an explanation to this proposal.
Company Name: ______________________________________
Authorized Signature: _________________________________
Printed Name & Title: __________________________________
Date: ________________________________________________
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