7-07. Submittal Form- Debarment or Suspension, Conflicts, Tax Lien, Responsiveness.docx
DOCX document 17 KB Posted
- Attached to
- UDOT IFB- Concrete Cylinder End Grinders (QTY 3)
- Solicitation number
- UDOT250245MP
- Issued by
- Utah
About this file
This is a submittal form for certifications and representations required by the State of Utah for the UDOT Invitation for Bid (IFB) to procure three concrete cylinder end grinders equivalent to or the same as the Humboldt H-2956A model. The form requires vendors to certify their status regarding debarment, suspension, or ineligibility by any government agency at the international, national, state, or local level. Vendors must also disclose any conflicts of interest or potential conflicts of interest that might arise during contract performance, declare whether they have outstanding tax liens in the State of Utah, and provide any other material information not already included in their proposal that could impact the state's determination of vendor responsiveness for contract award, including legal actions, significant personnel changes, loss of major contracts, or alleged violations of federal, state, or local regulations.
The form serves as a critical compliance document for bidders participating in the UDOT procurement process and must be completed truthfully with all affirmative responses requiring detailed explanations of circumstances. Failure to accurately complete this certification form or disclosure of material information that was not previously provided may result in bid rejection or disqualification from consideration for contract award. Vendors are directed to reference UCA 63G-6a-120 and 902 regarding other information disclosure requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| 4-02. Specifications- Cylinder Grinders.docx | DOCX document | |
| 2-06. Submittal Form- Pricing.doc | DOC document | |
| 6-03. Submittal Form- Vendor Set Up Form.pdf | ||
| 5-05. Attachment A- Agency Terms and Conditions.docx | DOCX document | |
| 3-04. Submittal Form- Business Confidentiality- check fields.doc | DOC document | |
| 1-01. IFB General Bid Information.doc | DOC 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):
File details come from the government source that posted it. Updated .