5-Form 5-Suspension Debarment Certification.docx
DOCX document 26 KB Posted
- Solicitation number
- OCC-2025-00028249
- Issued by
- Dallas County, Texas
About this file
This document is a Suspension/Debarment Certification form from the City of Dallas Office of Community Care and Empowerment (OCCE) related to the Housing Opportunities for Persons with AIDS (HOPWA) Program. The form is designed to verify that potential contractors, subcontractors, vendors, or nonprofit sub-recipients are not suspended or debarred from participating in federally funded contracts, specifically by cross-referencing the federal System for Award Management (SAM) excluded parties list.
The HOPWA grant program, funded by the U.S. Department of Housing and Urban Development (HUD), seeks multiple subrecipients to provide housing assistance and supportive services for low-income persons living with HIV in the Dallas eligible service area. Service categories include Emergency/Tenant Based Rental Assistance, Facility Based Housing, Emergency Vouchers, Master Leasing, Housing Information Services, Supportive Services Only, and Facility Rehabilitation/Repair or New Construction. The certification form requires detailed organizational information, including federal tax ID, SAM Unique Entity Identifier, ownership structure, executive leadership, and board membership to ensure compliance with federal grant requirements.
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Text version
City of Dallas Office of Community Care and Empowerment
Form 5 Suspension/Debarment Certification
Instructions: Please complete items 1. through 15. below. If an item is not applicable, indicate N/A.
1. Project Address:
2. Completed by:
Name:
Date:
The Suspension/Debarment Certification consists of the responsible department comparing the following contractor information against the federal System for Award Management (SAM) excluded parties list (available on the Internet at www.sam.gov) and documenting the clearance or rejection of the contractor. By execution of this form, the contractor, subcontractor, vendor, or nonprofit sub-recipient is certifying that the organization and its owner(s) and principal(s) are not suspended or debarred from participation in any federally funded contract.
3. Federal Tax ID Number:
4. SAM Unique Entity Identifier (UEI)
5. DUNS Number (if available):
6. Name of Organization (with d/b/a):
7. Address of Organization:
| 8. | Sole Proprietorship: |
| First Name | |
| Middle Name/Initial | |
| Last Name |
(List all Owners)
| 9. | Partnership: |
| First Name | |
| Middle Name/Initial | |
| Last Name |
(List all Partners.
For Corporate Partners, complete Items 10 & 11 below,)
| 10.Corporation: |
| Title |
| First Name |
| Middle Name/Initial |
| Last Name |
| (List all EXECUTIVES and their titles if different than shown) |
| President & Chief Executive Officer, or Executive Director |
Chief Operating Officer
Chief Financial Officer
| 11. Corporation: |
| Title |
| First Name |
| Middle Name |
| Last Name |
| (List all BOARD MEMBERS in |
| Chair |
| alphabetical order) |
| Vice Chair |
Secretary
Treasurer
| 11. Corporation: |
| Title |
| First Name |
| Middle Name/Initial |
| Last Name |
| (continued) |
| Board Member: |
Board Member:
Board Member:
Board Member:
Board Member:
Board Member:
Board Member:
Board Member:
Board Member:
Board Member:
Board Member:
(Use additional sheets if needed)
12. Federal Grant-Funded Project (if known) The above Organization is under consideration for selection to work on the following:
Grant Name/Project:
Federal Agency:
Assistance Listing Number: (formerly CFDA Number)
13. NAME of Organization
14. SIGNATURE on behalf of Organization
15. DATE
FOR CITY OF DALLAS USE ONLY:
I hereby certify that I conducted an on-line search of the excluded parties list found at www.sam.gov based on the information provided by the Organization above. Results of the search are attached here.
Signature of Reviewer:
Date:
I hereby certify that, by the completion of this form, the City of Dallas has fully complied with the requirements of 2 CFR Part 180 and Appendix II to 2 CFR Part 200, Paragraph (I), pertaining to not using suspended or debarred organizations to conduct federally funded projects.
Signature of Certifying Officer:
Date:
Department Director (or designee)
Suspension/Debarment Certification - Page 2 of 2 Issued: 7/1/2022 Revised 1/1/2025
File details come from the government source that posted it. Updated .