Response_Form_Culvert.docx

AG-9AC7-S-16-0084

Humbug Culvert Supply: Susanville, California Lassen National Forest – Lassen County Response Form

Vendor Name_________________________

DUNS #______________________________

24‐ inch equivalent corrugated steel pipe arch, 14 gauge, 20 foot length

Each

24‐ inch equivalent corrugated steel pipe arch coupling band

Each

60‐ inch equivalent corrugated steel pipe arch, 12 gauge, 20 foot length

Each

60‐ inch equivalent corrugated steel pipe arch, 12 gauge, 10 foot length

Each

60‐ inch equivalent corrugated steel pipe arch coupling band

Each

Total Cost

AGAR 452.209-70 Representation by Corporations Regarding an Unpaid Delinquent Tax Liability or a Felony Conviction (FEB 2012) -- Alternate I (FEB 2012) (DEVIATION)

(a.) Awards made under this solicitation are subject to the provisions contained in the Consolidated Appropriations Act, 2012 (P.L. No. 112-74), Division E, Sections 433 and 434 regarding corporate felony convictions and corporate federal tax delinquencies. To comply with these provisions, all offerors must complete paragraph (1) of this representation, and all corporate offerors also must complete paragraphs (2) and (3) of this representation.

(b.) The Offeror represents that –

(1) The Offeror is |_|, is not |_| (check one) an entity that has filed articles of incorporation in one of the fifty states, the District of Columbia, or the various territories of the United States including American Samoa, Federated States of Micronesia, Guam, Midway Islands, Northern Mariana Islands, Puerto Rico, Republic of Palau, Republic of the Marshall Islands, U.S. Virgin Islands. (Note that this includes both for-profit and non-profit organizations.)

If the Offeror checked “is” above, the Offeror must complete paragraphs (2) and (3) of the representation. If Offeror checked “is not” above, Offeror may leave the remainder of the representation blank.

(2) (i) The Offeror has |_|, has not |_| (check one) been convicted of a felony criminal violation under Federal or State law in the 24 months preceding the date of offer.

(ii) Offeror has |_|, has not |_| (check one) had any officer or agent of Offeror convicted of a felony criminal violation for actions taken on behalf of Offeror under Federal law in the 24 months preceding the date of offer.

(3) The Offeror does |_|, does not |_| (check one) have any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Name of Company:____________________________________________

Name of Company Representative: _______________________________

Date:_________________________