5-Submittal Form- Debarment or Suspension, Conflicts, Tax Lien, Responsiveness.docx
DOCX document 19 KB Posted
- Solicitation number
- UDOT2600128MH-1
- Issued by
- Utah
About this file
This is a submittal form for certifications related to a Request for Proposal (RFP) from the Utah Department of Transportation (UDOT) for a Utah Broadband BEAD Consultant to support the Utah Broadband Center. The form requires vendors to certify their status regarding debarment, suspension, ineligibility declarations, conflicts of interest, outstanding tax liens in Utah, and any other information that could impact the State's determination of vendor responsiveness. Vendors must answer whether they have been debarred, suspended, proposed for debarment, or declared ineligible by any government department or agency at international, national, state, or local levels; respond to potential conflicts of interest that might arise during contract performance; disclose any outstanding tax liens in the State of Utah; and reveal any material information not already provided in their proposal that could affect the State's evaluation, including legal actions, personnel changes, contract losses, or alleged regulatory violations. This solicitation is anticipated to result in a single contract award.
The form requires vendors to provide detailed explanations if they answer affirmatively to any of the certification questions. Vendors must demonstrate compliance with federal grant administration standards under 2 CFR 200 and possess expertise in telecommunications and broadband industry regulatory matters. The consultant team will provide expert guidance on administration, compliance, and subgrantee contracting for the federal Broadband Equity, Access, and Deployment (BEAD) Program. All responses must follow Utah Department of Transportation standards and specifications.
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| 1-6. Form- Business Confidentiality- check fields.doc | DOC document | |
| 4-8. FI170 (1).pdf | ||
| 2-3. Form- Cost Proposal Form.doc | DOC document | |
| 7-1.1 RFP General Information-BEAD Consultant .docx | DOCX document | |
| 8-2.1 SOW.docx | DOCX document | |
| 9-5.1 Sample Proposal Evaluation Scoresheet with drop down (1).docx | DOCX document | |
| 3-7. w-9 (2024 version).pdf | ||
| 6-4. Terms and Conditions Corrected.docx | DOCX document |
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Text version
Certifications- Debarment, Conflict of Interest, Outstanding Tax Lien, Other Information
1. DEBARMENT- Is vendor presently or has vendor ever been debarred, suspended, proposed for debarment, or declared ineligible by any government department or agency, whether international, national, state, or local? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I have not been debarred, suspended, proposed for debarment, or declared ineligible.
Yes, I am or have been debarred, suspended, proposed for debarment, or declared ineligible (see as follows):
2. CONFLICT OF INTEREST- Does Vendor have any conflict, or potential conflict of interest, that might arise during the contract? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have any Conflict or Potential Conflict of Interest.
Yes, I do have a Conflict or Potential Conflict of Interest (see as follows):
3. OUTSTANDING TAX LIEN- Does vendor have an outstanding tax lien in the State of Utah? If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have an outstanding Tax Lien.
Yes, I do have an outstanding Tax Lien (see circumstances as follows):
4. OTHER INFORMATION- Does vendor have any information that is not already provided within its proposal that if known to the State would impact the State’s determination on vendor's responsiveness for a contract award (i.e., legal action, recent turn-over in major personnel, loss of a major contract, any alleged violations of federal, state or local regulations, etc.). Please see UCA 63G-6a-120 & 902. If answer is "Yes", vendor must provide a statement explaining the circumstances.
No, I do not have any Other Information.
Yes, I do have Other Information (see as follows):
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