5-07. Submittal Form- Certifications- Yes No.docx
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- Solicitation number
- UDOT270067MP
- Issued by
- Utah
About this file
This is a submittal form containing certification requirements for vendors bidding on a Utah Department of Transportation (UDOT) Invitation for Bid (IFB) for Pavement Marking Waterborne Traffic Paint. The form requires vendors to certify their compliance status regarding four key areas: debarment history with any government entity; conflict of interest concerns; outstanding tax liens in the State of Utah; and any other material information that could impact the state's determination of vendor responsiveness and contract award eligibility. Vendors must respond affirmatively or negatively to each certification category, with detailed written explanations required for any "yes" responses.
The certification form is mandatory for all bidders and aligns with provisions of the Utah Procurement Code, specifically UCA 63G-6a-120 and 902. Vendors are required to disclose any previous debarment or suspension actions; potential conflicts of interest arising during contract performance; existing tax liens; and any other relevant circumstances including legal actions, personnel changes, loss of major contracts, or alleged violations of federal, state, or local regulations. The form serves as a pre-award compliance mechanism to ensure that only responsive and responsible vendors are considered for the contract to supply waterborne pavement marking paint in white, yellow, and black colors meeting UDOT standard specification 02765.
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Certifications- Debarment, Conflict of Interest, Outstanding Tax Lien, Other Information
1. DEBARMENT- Is vendor presently or has vendor ever been debarred, suspended, proposed for debarment, or declared ineligible by any government department or agency, whether international, national, state, or local? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I have not been debarred, suspended, proposed for debarment, or declared ineligible.
Yes, I am or have been debarred, suspended, proposed for debarment, or declared ineligible (see as follows):
2. CONFLICT OF INTEREST- Does Vendor have any conflict, or potential conflict of interest, that might arise during the contract? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have any Conflict or Potential Conflict of Interest.
Yes, I do have a Conflict or Potential Conflict of Interest (see as follows):
3. OUTSTANDING TAX LIEN- Does vendor have an outstanding tax lien in the State of Utah? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have an outstanding Tax Lien.
Yes, I do have an outstanding Tax Lien (see circumstances as follows):
4. OTHER INFORMATION- Does vendor have any information that is not already provided within its proposal that if known to the State would impact the State’s determination on vendor's responsiveness for a contract award (i.e., legal action, recent turn-over in major personnel, loss of a major contract, any alleged violations of federal, state or local regulations, etc.). Please see UCA 63G-6a-120 & 902. If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have any Other Information.
Yes, I do have Other Information (see as follows):
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