7-SAM Certification.pdf
PDF 74 KB Posted
- Attached to
- Louisville Metro Land Development Code Update
- Solicitation number
- RFP260096
- Issued by
- Bath County, Kentucky
About this file
This document is a Certification Regarding Debarment, Suspension and Other Responsibility form designed for a business entity to complete. The form requires the authorized representative of a business to certify whether the business and its principals are currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in federal transactions.
The form provides two checkbox options: one to certify that the business is not presently debarred or suspended, and another to indicate an inability to certify the statement, in which case an explanation must be attached. The form requires the signature, printed name, title, and date from an authorized representative of the business entity. This certification is a standard compliance document typically required when a business is seeking to engage in a federal transaction or contract.
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Text version
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION AND OTHER RESPONSIBILITY
Business Entity Name
PLEASE MARK ONE:
___ I hereby certify that, as of ________________, to the best of my knowledge and belief, ________________________________________, and its principals are not presently debarred, suspended, proposed for debarment declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.
___ I am unable to certify to any of the statements in this certification and an explanation is hereby attached.
Signature of Authorized Representative
Printed Name of Authorized Representative
Title, Role or Capacity of Authorized Representative
Date
| Printed Name of Authorized Representative: |
| Title Role or Capacity of Authorized Representative: |
| Check Box1: Off |
| Check Box2: Off |
| Date 1: |
| Date 2: |
| Business Entity Name: |
File details come from the government source that posted it. Updated .