5-Attachment D-1 - Required Forms Affidavits (Federal) 2.pdf
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- Solicitation number
- 547742
- Issued by
- Wayne County, Detroit City, Michigan
About this file
This document is an Attachment D-1 Forms, Affidavits and Documentation Checklist required for contract proposals submitted to the City of Detroit Office of Contracting and Procurement in support of a Media Strategist, Planning and Buying solicitation funded through grant funding. The solicitation seeks qualified respondents to provide media planning, strategy development, and media buying services to support multiple City of Detroit departments' marketing campaigns over a three-year contract period. Contractors must complete and submit all required forms and supporting documentation with their application proposals, including certificates of authority, notarized affidavits of disclosure of interests, non-collusion affidavits, amendment acknowledgments, Byrd Anti-Lobbying Certifications, federal regulation compliance documents, and debarment and suspension certifications. Failure to submit completed forms and documentation may result in proposal rejection.
The document provides templates and instructions for various organizational entity types, including limited liability companies, unincorporated associations, and corporations, to establish authorized signatories for contract execution. Additionally, the checklist requires contractors to disclose any financial interests, real or personal property subject to City decisions, immediate family members employed by or seeking employment with the City, and any subcontractors or vendors who participated in developing the solicitation project. All disclosures must be notarized and accompanied by affirmations of accuracy. The document references the 2012 Detroit City Charter sections governing disclosure requirements and defines key terms such as immediate family members to ensure comprehensive conflict-of-interest identification and transparency in the procurement process.
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Attachment D-1
FORMS, AFFIDAVITS AND DOCUMENTATION CHECKLIST
Any contract/purchase order resulting from this solicitation shall include the forms indicated below. Contractor shall complete the required forms and submit them with the application.
Failure to submit the completed forms and documentation may be a basis for rejection of your proposal.
Completed Documents REQUIRED WITH APPLICATION Notes
Certificate of Authority Select the applicable form and complete (applicant may submit their own Resolution of Authority)
Affidavit of Disclosure of Interests Read and Complete; Must be notarized
□ Non-Collusion Affidavit Read and Complete; Must be notarized
Amendment Acknowledgment Read and Complete if applicable
□ Byrd Anti-Lobbying Certification
Read and Complete
Federal Regulation and General Grant Terms and Conditions (Copeland Anti-Kickback)
Enter applicant's entity name in first paragraph and read required terms and conditions
Debarment and Suspensions
Read and Complete
LIMITED LIABILITY COMPANY CERTIFICATE OF AUTHORITY
I, ------------------------------------------------ �aManagerorMember
(name of manager) of ______________________ ,L.L.C, a limited liability company (the "Company"), DO
(name of company)
HEREBY CERTIFY that I am a Manager or Member of the Company who has the authority to act as an agent of the Company in executing this Certificate of Authority. I further certify that the following individuals are Managers or Members of the Company who have the authority to execute and commit the Company to the conditions, obligations, stipulations and undertakings contained in the foregoing Contract between the City and the Company:
FURTHER, I CERTIFY that all necessary approvals by the Managers or Members of the
Company have been obtained with respect to the execution of said Contract.
IN WITNESS THEREOF, I have set my hand this _day of , 20 _
COMPANY SEAL( if any)
Manager or Member
PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON BEHALF
OF YOUR LIMITED LIABILITY COMPANY MUST BE ONE OF THE INDIVIDUALS
LISTED ABOVE AS A PERSON AUTHORIZED TO EXECUTE CONTRACTS IN THE
NAME OF AND ON BEHALF OF THE LIMITED LIABILITY COMPANY.
Rev. 11/30/2022
Rev. 11/30/2022 Pages
UNINCORPORATED ASSOCIATION CERTIFICATE OF AUTHORITY
I, _,Secretary of _, (name of association secretary) an unincorporated association (the "Association"), DO HEREBY CERTIFY that the following is a true and correct excerpt from the minutes of the meeting of the Board of
Directors duly called and held on , and that the same is now in full
(date of meeting)
Force and effect:
"RESOLVED, that the Chairman, the President, each Vice President, the Treasurer, and the
Secretary and each of them, is authorized to execute and deliver, in the name of an on behalf of the Association and under its Association seal or otherwise, any agreement or other instrument or document ('Contract") in connection with any matter or transaction that shall have been duly approved; and the execution and delivery of any Contract by any of the aforementioned officers shall be conclusive evidence of such approval."
FURTHER, I CERTIFY that --------------------------- �is Chairman
,is President, ,is/are Vice President(s), is Treasurer, ,is Secretary, ,is Executive Director, and
�lS _
FURTHER, I CERTIFY that any of the aforementioned officers of the Association are authorized to execute or guarantee and commit the Association to the conditions, obligations, stipulations, and undertakings contained in the foregoing Contract between the City and the above-referenced
Association and that all necessary Association approvals have been obtained in relationship thereto.
IN WITNESS THEREOF, I have set my hand this d.ay of � 20
CORPORATE SEAL (if any)
Association Secretary
PLEASE NOTE THAT THE PERSON WHO SIGNS THE CONTRACT ON
BEHALF OF YOUR ASSOCIATION MUST BE ONE OF THE INDIVIDUALS
LISTED ABOVE AS A PERSON AUTHORIZED TO EXECUTE CONTRACTS IN
THE NAME OF AND ON BEHALF OF THE ASSOCIATION.
Page?
Interested Party (if an immediate famity member, please provide an address and phone number and the nature of the relationship to the filer): Name _
Street Address _
City _
State Zip code Telephone _
Relationship _
Nature of financial interest _
Estimated value of the financial interest _
Section 3 - Interests in Property Subject to Decision by City (City Charter§ 2-106.2.tfc): City Code§ 2-5-34(a)(.3))
The above-named contractor or vendor; its direct and/or indirect owners, officers, directors, and managers; and/or an immediate family member of any owner, officer, director, or manager thereof
0 has (if checked, complete rest of section below)
0 does not have (if checked, skip to next section) an interest in real or personal property that is subject to a decision by the City regarding the 2urchase, sale, lease, zoning, improvement, special designation tax assessment or abafemenf or a clevelopment agreement.
Interested Party (if an immediate family member, please provide an address and phone number and the nature of the relationship to the filer): Name _
Street Address _
City _
State Zip code _
Telephone Relationship _
Description of real or personal property _
Nature of interest _
Estimated value of the interest _
Section 4 - Immediate Famil}: Members Employed by or Seeking Employment with City (City Charter§ 2- 106.2.t(e): City Code § 2-5-34(a)(5))
Please identify any immediate family member of the filer, including any immediate family members of a direct or mdirect owner, officer, director, or manager thereof, who is currently employed by or applying for employment with the City of Detroit.
Page9
List the City employees with whom the Vendor assisted with the Solicitation:
Please list any of Vendor's subcontractors or proposed subcontractors that contributed information, exP.ertise or m any other way participated in the creation of the project underlying the Solicitation, including, but not limited to, participation in the creation of the scope of the project,1he requirements of the project, or the budget required for the project, along with the nature and extent of the subcontractor's contribution: _
Section 7 - Affirmation of Accuracy of Disclosure tcity Charter§ 2-106.2.3: City Code§ 2-5-34(b))
I understand that the information P.rovided in this disclosure will be relied upon by the City of Detroit in evaluating the proposed bid, solicitation, contract., or lease. I swear [or affirm] that the information provided is accurate. If I am signing on behalf or an entity1 I swear Lor affirm] that I have made a goocffaith and reasonable effort to verity the information provided herem, and further, that I have the authority to provide this disclosure on behalf of the entity.
Sign name:
Print name: _
Sworn and subscribed to before me on ., 20_ by , the-----��--------- -[name] [title] of the and am an authorized representative of that entity. [legal entity/company]
Sign: _
Print: _
Notary Public, County, Michigan, Acting in County
My Commission Expires: _
Notary Seal
REFERENCES FOR DISCLOSURES BY CONTRACTORS AND VENDORS
2012 Detroit City Charter
Sec. 2-105. - Definitions and Rules of Construction.
A. As used in this Charter:
20. Immediate family member means a Public Servant's spouse, domestic partner, individual who lives in the Public Servant's household or an individual claimed by a Public Servant or a Public Servant's spouse as a dependent under the United States Internal Revenue Code at 26 USC 1, et seq.
Sec. 2-106.2. - Disclosures.
1. Except as otherwise provided by applicable law, a Public Servant who exercises significant authority shall disclose:
a. Any financial interest, direct or indirect, that he or she or an immediate family member has in any contract or matter pending before City Council.
b. Any financial interest, direct or indirect, that he or she or an immediate family member has i�any contract or matter pending before or within any office, department or agency of the City.
c. Any interest that he or she, or an immediate family member has in real and personal property that is subject to ? de<:ision by the City regarding purchase, sale, lease, zoning, improvement, special designation tax assessment or aoatement or a development agreement.
d. Campaign contributions and expenditures, in accordance with applicable laws.
e. The identity of any immediate family member employed by the City or who is making application to the City.
2. In addition to compliance with subsection (1) above, contractors and vendors shall disclose:
a. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before City Council.
b. The identity of all entities and persons with any financial interest, direct or indirect, in any contract or matter the vendor or contractor has pending before or within any office, department, or agency of the City.
3. The above disclosures shall be made in writing and be made by sworn, notarized affidavit, in accordance with City ordinance and applicable laws.
NON-COLLUSION AFFIDAVIT
Solicitation No.
Solicitation Title:
State of , County of
S.S.
I state that I am of_-=-----.--,------.,..,..----, and that I am authorized to make this affidavit on behalf of my firm_1 and its ownershdirectors, and, officers. I am the person responsible in my firm for the price{s) ana the amount oft is RFP.
I state that:
The price(s) and amount of this proposal has been arrived at independently and without consultation, influence, communication or agreement with (i) any other contractor, vend.or or_potential vendor, or
(ii) the City of Detroit, including any of its departments, boards, commissions, officers, employee, or agents.
Neither the price(s) nor the amount of this proposal, and neither the approximate price(s) nor approximate amount of this proP.osal, have been disclosed to any other firm or person who is a vendor or potential vendor, and they will not be disclosed before the bid opening.
No attempt has been made or will be made to induce any firm or person to refrain from responding to this contraC;t\ or to submit a proposal higher than this proposal, or to submit any intentionally higfi or noncompetitive proposal or other form of complementary proposal.
The proposal of my firm is made in good faith and not pursuant to any agreement or discussion with, or inducement from, any firm or person to submit a complementary or other noncompetitive proposal, including, but not limited to, any agreement to circumvent any regulatory or City requirements that may be applicable.
, its affiliates, subsidiaries, officers, directors and employees a_r_e_n_o_t_c_u_r_r_e_n_,tl,...y_u_n_d,..e_r_,,i,....n_v_e-st....,.ig_a_t..,..io-n--rby any governmental agency and have not in the last five years been convicted or found liable for any act prohibited by state or federal law in any jurisdiction, involving conspiracy or collusion with respect to submitting a proposal on any public contract, except as follows: _
I state that -=------�-----understands and acknowledges that the above representations are material and important, and will be relied on by the City of Detroit in awarding the contract(s)/ purchase order(s) for which this proposal is submitted. I understand and my firm understands tfiat any misstatement in this affidavit is and shall be treated as fraudulent concealment from the City of Detroit's Office of Contracting and Procurement of the true facts relating to the submission of this
RFP.
Printed Name & Title of Authorized Representative:
Signature of Authorized Representative:
Date: _
AMENDMENT ACKNOWLEDGEMENT FORM
Project/Solicitation No.:
Project Title:
The undersigned acknowledges receipt of the following amendments to the solicitat1on document:
Amendment No. , Dated. Company
Name:
Authorized Signature:
Name: (Print)
Title:
Date:
The Contractor,�----�------:, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agr:ees that the provisions of 31 U.S.C. Chap. 38 Administrative Remedies for False Claims and Statements, apply to this certification and disclosure, if any.
Signature of Contractor's Authorized Official
Name and Title of Contractor's Authorized Official
Date selection for training, in- eluding apprenticeship. The Contractor agrees to post in conspicuous places, available to empfoy- ees and applicants for employment, notices to be provided setting forth the provis10ns of this non- discrimination clause.
(b) The Contractor will, in all solicitations or advertisements for employees placed by or on behalf of the Contractor, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.
(c) The Contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because such employee or applicant has in9.mred about, discussed, or disclosed the compensation of the emI?loyee or apphcant or another employee or applicant. This provision shall not apply to instances in which an empfoyee who has access to the compensation information of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to mdividuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the Contractor's legal duty to furnish information.
(d) The Contractor will send to each labor union or representative of workers with which he has a collective bargaining agreement or other Contract or understanding, a notice to be provided advising the said labor union or workers' representatives of the Contractor's commitments under this section, and shall post copies of the notice in conspicuous places available to employees and applicants for employment.
(e) The Contractor will comply with all provisions of Executive Order 11246 of Sep- tember 24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor.
(f) The Contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by rules, regulat10ns, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by tlie administering agency and the Secretary of Labor for pul])oses of investigation to ascertain compliance with such rules, regulations, and orders.
(g) In the event of the Contractor's noncompliance with the nondiscrimination clauses of this Contract or with any of the saia. rules, regulations, or orders, this Contract may be canceled, terminated, or suspended in wliole or in part and the Contractor may be declared ineligible for further Government Contracts program with respect to which the failure or refund occurred until satisfactory assurance of future compliance has been received from such City of Detroit; and refer the case to the Department of Justice for appropriate legal proceedings.
IV. Federal Compliance
(a) Consistent with the Davis-Bacon Act (40 U.S.C. 3141-3148), the parties agree as follows:
1. All transactions regarding this Contract shall be done in compliance with the Davis- Bacon Act (40 U.S.C. 3141- 3144, and 3146-3148) and the requirements of 29 C.F.R. pt. 5 as may be applicable. The Contractor shall comply with 40 U.S.C. 3141-3144, and 3146-3148 and the requirements of 29
C.F.R. pt. 5 as applicable.
2. Contractors are required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination made by the Secretary of Labor.
3. Contractors are required to pay wages not less than once a week. This subsectiOJ? (a) is applicable only to the extent the Contract pertains to construct10n work.
(b) Consistent with the Copeland Anti-Kickback Act, the parties agree as follows:
1. The Contractor shall comply with 18 U.S.C. § 874, 40 U.S.C. & 3145, and the require- ments of 29 C.F.R. pt. 3 as may be applicable, which are incorporated by reference into this Contract.
2. The Contractor or subcontractor shall insert in any subcontracts the clause above and such other clauses as may by appropriate instructions, and also a clause requiring the subcontractors to include these clauses in any lower tier subcontracts. The prime Con- tractor shall be responsible for the compliance by any subcontractor or lower tier sub- contractor with all of these Contract clauses.
3. A breach of the Contract clauses above may be grounds for termination of the Contract and for debarment as a Contractor and subcontractor as provided in 29 C.F.R. § 5.12.'
4. This subsection (l?) is applicable only to the extent the Contract pertains to construction work,
(c) Consistent with the Contract Work Hours and Safety Standards Act (40
U.S.C. 3701- 3708), the parties agree as follows:
Page23
I. The Contractor agrees to comply with all applicable standards, orders or regulations issued pursuant to tfie Clean Air Act, as amended, 42 U.S.C. § 7401 et seq.
2. The Contractor agrees to report each violation to the City of Detroit and understands and agrees that the Contractor will, in turn, report each violation as required to assure notification to the granting federal agency, and the appropriate Environmental Protec- tion Agency Regional Office.
3. The Contractor agrees to include these requirements in each subcontract exceedmg $150,000 financed in whole or in part with Federal assistance provided by tfie granting federal agency.
4. The Contractor agrees to comply with all applicable standards, orders, or regulations issued pursuant to tfie Federal Water Pollution Control Act, as amended, 33 U.S.C. 1251 et seq.
5. The Contractor agrees to report each violation to the City of Detroit and understands and agrees that the City of Detroit will, in turn, report each violation as required to assure notification to the Federal Emergency Management Agency, and the appropriate Environmental Protection Agency RegionafOffice.
6. This subsection (d) is applicable only to the extent the Contract is for a sum @"eater than bne Hundred Fifty Thousand and 00/100 Dollars (�150,000.00),
(e) Consistent with the Byrd Anti-Lobbying Amendment (31 U.S.C. § 1352, as amended), the parties agree as follows:
1. Contractors who apply or bid for an award of $100,000 or more shall file the required certificat10n. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, officer or em- ployee of Congress, or an employee of a Member of Congress in connection with ob-taimng any Federal Contract, grant, or any other award covered by 31U.S.C.
§ 1352.
2. Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the recipient who in turn will forward the certification(s) to the awarding agency.
1. Recipients and subrecipients are prohibited from obligating or expending loan or grant funds to (i) procure or obtain; (ii) extend or renew a contract to procure or obtain; or (iii) enter into a contract (or extend or renew a contract) to procure or obtain equipment, services, or systems that uses coverea telecommunications equipment or services as a substantial or essential component of any system. As described in Public Law 115-232, section 889, covered telecommunications equip-ment is telecommunications equipment produced by Huawei Tedinologies Com- pany or ZTE Corporation (or any subsidiary or affiliate of sucb entities).
i. For the rurpose of public safety, security of government facilities, physica security surveillance of critical infrastructure, and other national security purposes, video surveillance and telecommunications equipment produced by Hytera Communications Corporation, Hangzhou Hikvis10n Digital Technology Company, or Dahua Tecfinology Company (or any subsidiary or affiliate of such entities).
11. Telecommunications or video surveillance services provided by such enti- ties or using such equipment.
111. Telecommunications or video surveillance eguipment or services produced or provided by an entity that the Secretary of Defense, m consultation with the Director of the National Intelligence or the Director of the Federal Bu- reau of Investigation, reasonably believes to be an entity owned or con- trolled by, or otherwise connected to, the government of a covered foreign country.
2. In implementing the prohibition under Public Law 115-232, section 889, subsection (t), paragraph (1), heads of executive agencies administering loan, grant, or subsidy programs shall prioritize available funding ana techmcal support to assist affecteo businesses institutions and organizations as is reasonably necessary for those af- fected entities to transition from covered communications equipment and services, to procure replacement equipment and services, and to ensure that communications service to users and customers is sustained.
(i) See Public Law115-232, section 889 for additional information. See also §200.471.Records
Requirements.
1. The Contractor agrees to provide the City, the federal granting agency, the
1. All transactions regarding this Contract and subject to the applicable law shall be done in compliance with the Federal Acquisitions Regulations guidance 6.302-2 (unusual and compelling urgency. The Contractor shall comply with 10 U.S.C. 2304(c)(2) or 41 U.S.C. 3304(a)(2), as well as Title 2 CFR 200(e) as applicable, which are incorporated by reference into this Contract and quoted in full below:
(a) Authority.
(1) Citations: 10 U.S.C.2304(c)(2) or 41 U.S.C.3304(a)(2).
(2) When the agency's need for the supplies or services is of such an unusual and compelling urgency that the Government would be seriously injured unless the agency is permitted to limit the number of sources from which it sohcits bids or proposals, full and open competition need not be provided for.
(b) Application. This authority applies in those situations where-
(1) An unusual and compelling urgency precludes full and open competition; and
(2) Delay in award of a contract would result in serious injury, financial or other, to the Government.
(c) Limitations.
{l) Contracts awarded using this authority shall be supported by the written justi- fications ancr approvals described in 6.303 and 6.304.
These justifications may be made and approved after contract award when preparation and approval prior to award would unreasonably delay the acquisition.
(2) This statutory authority requires that agencies shall request offers from as many potentia1 sources as 1s practicable under the circumstances.
(d) Period of Performance.
{l) The total period of performance of a contract awarded or modified using this authority-
(i) May not exceed the time necessary:
(A) To meet the unusual and compelling requirements of the work to be performed under the contract; and
(B) For the agency to enter into another contract for the required goods and services through the use of competitive procedures; and
(ii) May not exceed one year, including all options, unless the head of the agency determines that exceptional circumstances apply. This aeter- mination must be documented in the contract file.
(2)(i) Any subsequent modification using this authority, which will extend the period of performance beyond one year under this same authority, requires a sep- arate determination. This determination is only required if the cumulative period of performance using this authority exceeds one year. This requirement does not apply to the exercise of options previously addressed in the determination required at paragraph: (d)(l)(ii) of this section. (ii) The determination shall be
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Required Disclosures for Federal Awardee Performance and Integrity Information stem (FAPIIS): Consistent with 45 CFR 75.113, applicants and recipients must close in a timely manner, in writing to the CDC, with a copy to the HHS Office of
Inspector General (OIG), all information related to violations of federal criminal law
Involving fraud, bribery, or gratuity violations potentially affecting the federal award.
Subrecipients must disclose, in a timely manner in writing to the prime recipient ass through entity) and the HHS OIG, all information related to violations if federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the federal award. Disclosures must be sent in writing to the CDC and to the HHS OIG at the following addresses:
CDC, Office of Grants Services
Linda Brigham, Grants Management Specialist Centers for Disease Control and Prevention Office of Grants Services
2939 Flowers Road, MS TV-2 Atlanta, GA 30341
Telephone: 678.475.4904
Fax: 770-488-2640 (Include "Mandatory Grant Disclosures" in subject line) Email: srq9@cdc.gov
(Include "Mandatory Grant Disclosures" in subject line)
AND
U.S. Department of Health and Human Services Office of the Inspector General
ATTN: Mandatory Grant Disclosures, Intake Coordinator 330 Independence Avenue, SW
Cohen Building, Room 5527 Washington, DC 20201
Fax: (202)-205-0604 (Include "Mandatory Grant Disclosures" in subject line) or Email:
MandatoryGranteeDisclosures@oig.hhs.gov mailto:srq9@cdc.gov
DEBARMENT AND SUSPENSIONS CERTIFICATION
POLICY
Debarment and Suspension (Executive Orders 12549 and 12689) - A contract award (see 2 CFR 180,220) must not be made to 2arties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the 0MB @idelines at 2. CFR 180 that impfement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 1268g (3 CFR part 1989 Comp., R· 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred suspended, or otherwise excluded by agencies as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549.
CERTIFICATION OF PRIMARY PARTICIPANT REGARDING DEBARMENT,
SUSPENSION, AND OTHER RESPONSIBILITY MATTERS
Bidders/Proposer's Name certifies to the best of its knowledge and belief, that it and its principals:
1. Are not presently debarred suspended, proposed for debarment, declared ineligible voluntarily excluoed from coverea. 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 judw.nent rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal or State or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statemen1s, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph (2) of this certification; and
4. Have not within a three-year period preceding this application/pro2osal had one or more public transactions (Federal, State, or local) terminated for cause or default. If you are unable to certify to any of the statements in this certification, attach an explanation to this certification.
CERTIFICATION OF LOWER-TIER PARTICIPANTS REGARDING DEBARMENT,
SUSPENSION, AND OTHER INELIGIBILITY AND VOLUNTARY EXCLUSION
The Lower Tier Participant (potential subcontractor under a major third-party contract), ------=,-------:---,---,-------,--,----- ,.., certifies, by submission of this proposal, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
(If the Lower-Tier Participant (potential subcontractor under a major third-partY, contract) is unable to certify to any of the statements in this certification, such participant shall attach an explanation to this proposal).
THE LOWER-TIER PARTICIPANT (POTENTIAL SUBCONTRACTOR UNDER
CERTIFIES OR AFFIRMS THE TRUGHFULNESS AND ACCURACY OF THE
CONTENTS OF THE STATEMENTS SUBMITTED OR WITH THIS CERTIFICATION
AND UNDERSTANDS THAT THE PROVISIONS OF 31 U.S.C SECTION 3801 ET
SEQ. ARE APPLICABLE THERETO.
Signature and Title of Authorized Official
The undersigned chief legal counsel for the----= ----- =-- ,hereby certifies that the����� has authori!:)' under Stats and Local law to comply with the subject assurances and that the certification above has been legally made.
Signature of Applicant's Attorney
Date
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