5-11-Attachment-4 Suspension-and-Debarment-Certification.pdf

SUSPENSION AND DEBARMENT CERTIFICATION FORM

The Vendor certifies that, neither the Vendor firm nor any owner, partner, director, officer, or principal of the Vendor, nor any person in a position with management responsibility or responsibility for the administration of federal funds:

1. Is presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from covered transactions by any federal or state department/agency;

2. Has within a three-year period preceding this certification been convicted of or had a civil judgment rendered against it for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public transaction or contract (federal, state, or local); violation of federal or state antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

3. Is 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 paragraph (2) above; or,

4. Has within a three-year period preceding this certification had one or more public transactions or contracts (federal, state, or local) terminated for cause or default.

The Vendor certifies (check one):

☐ it is not registered with the System for Award Management (SAM.gov)

☐ it is not “Actively” registered with the System for Award Management (SAM.gov) but has been assigned the following UEID Number: ___________________________________.

☐ it is “Actively” registered with the System for Award Management (SAM.gov) and has been assigned the following UEID Number: ___________________________________.

The Vendor further certifies that it shall not knowingly enter into any transaction with any subcontractor, material supplier, or vendor who is debarred, suspended, declared ineligible, or voluntarily excluded from covered transactions by any federal or state department/agency.

Signature of Vendor’s Authorized Official Date

Name and Title of Vendor’s Authorized Official