AFFIDAVIT_OF_COMPLIANCE_-_DISADVANTAGED_BUSINESS_ENTERPRISE.pdf

608 KB Posted

Attached to
VoIP Phones
Solicitation number
2022-14
Issued by
Essex County, Kentucky

About this file

Written by GovTribe AI ·

This document is an Affidavit of Compliance for a Disadvantaged Business Enterprise (DBE) form issued by Lextran, a transit agency. The form is designed to be completed by proposers or subcontractors who qualify as a Disadvantaged Business Enterprise, requiring the authorized representative to declare and affirm their DBE status. The affidavit requires the company representative to provide their title, company name, and company address, and commit to providing additional documentation to Lextran verifying their DBE classification if requested.

The form is a legal document that requires notarization, with spaces for the date, authorized signature, printed name, and notary public details. By signing, the representative solemnly declares under penalties of perjury that the information provided is true and correct, and that they are authorized to execute the affidavit on behalf of their company. This document appears to be part of a procurement process that encourages or requires participation of disadvantaged businesses, though the specific contract details are not contained within this form itself.

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AFFIDAVIT OF COMPLIANCE - DISADVANTAGED BUSINESS ENTERPRISE

To be filled out only by proposers that are Disadvantaged Business Enterprise (DBE) or subcontractors who are DBE.

State of ____________________________

County of __________________________

I hereby declare and affirm, that I am the _____________________________________________ (Title)

And duly authorized representative of ________________________________________________ (Company Name)

Company address: ___________________________________________________________________

I hereby declare and affirm that I am a Disadvantaged Business Enterprise (DBE) as defined by the specifications and that I will provide information requested by Lextran to document this fact.

I do solemnly declare and affirm, under the penalties of perjury, that the contents of the aforementioned document are true and correct and that I am authorized, on behalf of the above firm, to execute this affidavit.

DATE: ___________________________________________________________

AUTHORIZED SIGNATURE: _______________________________________

PRINT NAME: ___________________________________________________

Sworn to before me and subscribed in the presence this ______ day of __________________, 20_____.

Notary Public Name: ______________________________________________________

Notary Public Signature: ___________________________________________________

My Commission Expires: ____________________________________

Company address:
I hereby declare and affirm that I am the:
And duly authorized representative of:
undefined:
PRINT NAME:
Sworn to before me and subscribed in the presence this:
day of:
20:
Notary Public Name:
Signature1_es_:signer:signature:
Signature2_es_:signer:signature:
Text3:
Text4:
Date5_es_:signer:date:
Date6_es_:signer:date:

File details come from the government source that posted it. Updated .