7-CERTIFIED STATEMENT DEPARMENT.pdf
PDF 209 KB Posted
- Attached to
- Rebid of Garbage Contract
- Solicitation number
- Not on record
- Issued by
- Monroe County, Pennsylvania
About this file
The document is a Certified Statement (Debarment) form for the State of Pennsylvania, Monroe County. The form is designed for a company president or owner to swear under oath that neither the company nor its leadership has ever been placed on a county, state, or federal debarment list as a result of work performed on government projects.
The form requires the company representative to personally appear before a notary, provide their name and company name, and attest to their lack of previous debarment. The document includes spaces for the individual's signature, name, title, and the notary's details, including the date of signing and the notary's commission expiration. This form serves as a legal certification of the company's good standing and eligibility to bid on or perform government contract work.
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Text version
CERTIFIED STATEMENT (DEBARMENT)
STATE OF PENNSYLVANIA)
)SS
COUNTY OF MONROE
On this __________________ day of ________________, before me personally came and appeared ( ), to me known, who being by me duly (Name)
Sworn did depose and say that he/she is the president/owner of ( ) (circle one) (Company Name) And that neither the company or the president/owner of the company has ever been placed on a (circle one) County, state, or federal debarment list as a result of work performed on county, state, or federal projects.
Signature
Name and Title
SUBSCRIBED AND SWORN TO BEFORE ME THIS
____________DAY OF ______________,20____.
BY:_____________________________________
TITLE:___________________________________
MY COMMISSION EXPIRES ____________ 20___
File details come from the government source that posted it. Updated .