Appendix A Debarment Forms RFQ 17A 241007_0080 Revised.pdf

State of Maine RFQ# 17A 241007-0080 Rev. 9/12/2024

Appendix A

STATE OF MAINE

DEPARTMENT OF ADMINISTRATIVE AND FINANCIAL SERVICES

DIVISION OF PROCUREMENT SERVICES

RFQ #17A 241007-0080

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BID COVER PAGE and DEBARMENT FORM

Bidder’s Organization Name:

Chief Executive - Name/Title:

Tel: Fax: E-mail:

Headquarters Street Address:

Headquarters City/State/Zip:

(provide information requested below if different from above)

Lead Point of Contact for Bid - Name/Title:

Tel: Fax: E-mail:

Street Address:

City/State/Zip:

By signing below Bidder affirms:

• Their bid complies with all requirements of this RFQ;

• This bid and the pricing structure contained herein will remain firm for a period of 180 days from the date and time of the bid opening;

• That no personnel currently employed by the Department or any other State agency participated, either directly or indirectly, in any activities relating to the preparation of the Bidder’s proposal;

• That no attempt has been made or will be made by the Bidder to induce any other person or firm to submit or not to submit a proposal; and

• The undersigned is authorized to enter into contractual obligations on behalf of the above-named organization.

Name: Title:

Authorized Signature: Date:

State of Maine RFQ# 17A 241007-0080 Rev. 9/12/2024

Debarment, Performance, and Non-Collusion Certification

By signing this document, I certify to the best of my knowledge and belief that the aforementioned organization, its principals, and any subcontractors named in this proposal:

a. Are not presently debarred, suspended, proposed for debarment, and declared ineligible or voluntarily excluded from bidding or working on contracts issued by any governmental agency.

b. Have not within three years of submitting the proposal for this contract been convicted of or had a civil judgment rendered against them for:

i. fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a federal, state or local government transaction or contract.

ii. violating Federal or State antitrust statutes or committing embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

iii. are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or Local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and

iv. have not within a three (3) year period preceding this proposal had one or more federal, state or local government transactions terminated for cause or default.

c. Have not entered into a prior understanding, agreement, or connection with any corporation, firm, or person submitting a response for the same materials, supplies, equipment, or services and this proposal is in all respects fair and without collusion or fraud. The above-mentioned entities understand and agree that collusive bidding is a violation of state and federal law and can result in fines, prison sentences, and civil damage awards.

• Failure to provide this certification may result in the disqualification of the Bidder’s proposal, at the discretion of the Department.

To the best of my knowledge all information provided in the enclosed proposal, both programmatic and financial, is complete and accurate at the time of submission.

Name: Title:

Authorized Signature: Date: