5-RFP 03 Certification Debarment Suspension Form.pdf

CERTIFICATION REGARDING

DEBARMENT, SUSPENSION, AND

OTHER RESPONSIBILITY MATTERS –

PRIMARY COVERED TRANSACTIONS

Incorporated County of Los Alamos Procurement Division

101 Camino Entrada, Building 3 Los Alamos, NM 87544

Version: 20250318

Offeror Company Name:

Solicitation No.:

Solicitation Title:

(1) I or We, _______________________________________________________ (the “Offeror/Bidder”) hereby certify to the best of our knowledge and belief that neither the Offeror/Bidder nor any of its principals:

(a) are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal, state, or local department or agency; and

(b) have, within a 3-year period preceding this certification:

i. 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;

ii. been convicted under federal or state antitrust statutes arising out of submission of bids or proposals;

iii. been convicted of embezzlement, theft, forgery, bribery; falsification or destruction of records, receiving stolen property, or any other offense indicating a lack of business integrity or business honesty which currently, seriously and directly affects responsibility as a county contractor;

iii. violated contract provisions resulting in a deliberate failure without good cause to perform in accordance with the specifications or within the time limit provided in the contract;

or a recent record of preventable failure to perform or of unsatisfactory performance in accordance with the terms of one or more contracts; or;

iv. violated the ethical standards set forth in article IX of the County Procurement Code.

(c) are 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 (1) of this certification; and

(d) are not current or former County employees. If an Offeror/Bidder is a current or former County employee, Offeror/Bidder shall provide additional information as described in paragraph (2) of this certification; and

(e) are not considered to be an “immediate family member” of a County employee or public official. Immediate family means the employee’s or public official's spouse, parent, step-parent, child, step-child, sibling, step-sibling, half-sibling, grandparent, grandchild, aunt, uncle, niece, nephew, or their in-laws, or an individual claimed by the public official or his/her spouse as a dependent under the United States Internal Revenue Code; and

(f) have within a 3-year period preceding this certification had one or more public transactions or contracts (federal, state, or local) terminated for cause or default.

(2) If we are unable to certify any of the statements in this certification, we shall attach an explanation hereto.

Version: 20250318

(3) Certification to any of the statements in this certification will be thoroughly reviewed, and may not necessarily preclude the Offeror/Bidder from consideration for award.

(4) Falsification of any statement in this Form shall constitute grounds for non-consideration of the

Offeror’s/Bidders proposal or bid or rescinding of a contract award.

Authorized Signer Name:

Date:

Title: Signature: