5-Attachment G. Certification re Debarment Suspension.pdf
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- Solicitation number
- RFP-2025-028
- Issued by
- Milwaukee County, Mattoon Village, Wisconsin
About this file
This document is a Certification Regarding Debarment and Suspension form, which requires applicants to certify their legal and ethical standing for a public transaction or contract. The certification requires the applicant to attest that their principals, owners, officers, shareholders, key employees, directors, and member partners: (1) are not currently debarred or suspended from federal transactions; (2) have not been convicted of fraud or criminal offenses related to public transactions within the past three years; (3) are not currently indicted for criminal charges by governmental entities; and (4) have not had public transactions terminated for cause or default within the past three years.
The form provides space for an authorized signature, printed name, title, and company information, allowing the applicant to formally declare their compliance with these legal requirements. By signing, the applicant affirms under penalty of potential legal consequences that the statements made are true to the best of their knowledge and belief. This certification serves as a critical vetting mechanism to ensure the integrity and reliability of parties seeking to engage in public sector contracts or transactions at the federal, state, or local level.
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Text version
ATTACHMENT G
CERTIFICATION REGARDING
DEBARMENT AND SUSPENSION
The applicant certifies to the best of its knowledge and belief that its principals, owners, officers, shareholders, key employees, directors and member partners: (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 the date of 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, 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) are not presently indicted for or otherwise criminally charged by a governmental entity
(Federal, State or local) with commission of any of the offenses enumerated in (2) of this certification; and (4) have not within a three-year period preceding the date of this proposal had one or more public transactions (Federal, State or local) terminated for cause or default.
Authorized Signature: Date:
Printed Name: Title:
Company:
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