Appendix D - Debarment Form.pdf
PDF 38 KB Posted
- Attached to
- Case Management Software State and local contract opportunity
- Solicitation number
- 37-24-028
- Issued by
- Wayne County, Michigan
About this file
This document is a Certification Regarding Debarment, Suspension, and Other Responsibility Matters form related to the Wayne County Case Management Software procurement. The certification requires the prospective participant to affirm that they meet specific legal and ethical standards, including not being currently debarred or suspended from federal nonprocurement programs, not having had public transactions terminated for cause within the past three years, and not being criminally or civilly charged for fraud, antitrust violations, or other specified criminal offenses.
The form is designed to ensure the integrity of potential contractors by requiring them to disclose any past legal issues or current legal challenges that might compromise their ability to perform on a government contract. Participants must certify their compliance with these standards, understanding that false statements can result in proposal rejection, contract termination, and potential legal consequences including fines up to $10,000 or imprisonment for up to five years under 18 U.S.C. §1001. The document provides an option for participants who cannot certify full compliance to attach an explanation for review.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Appendix C - DBE Form.pdf | ||
| RFP 37-24-028 - Case Management Software - Appendix A.docx | DOCX document | |
| RFP 37-24-028 - Case Management Software.docx | DOCX document | |
| RFP 37-24-028 - Case Management Software - Appendix B.docx | DOCX document | |
| W-9 Form v10-18.pdf |
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Text version
Certification Regarding
Debarment, Suspension, and Other Responsibility Matters
The prospective participant certifies, to the best of its knowledge and belief, that ___________ and its principals:
1. Are not presently debarred, suspended; proposed for debarment, declared ineligible, or voluntarily excluded from participation in transactions under federal nonprocurement programs by any federal department or agency;
2. Have not, within the three year period preceding the proposal, had one or more public transactions {federal, state, or local} terminated for cause or default; and
3. Are not presently indicted or otherwise criminally or civilly charged by a government entity (federal, state, or local) and have not, within the three year period preceding the proposal, been convicted of or had a civil judgment rendered against it;
(a) For the commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public transaction {federal, state, or local} or a procurement contract ·under such a public transaction;
(b) For the violation of federal or state antitrust statutes, including those proscribing price fixing between competitors, the allocation of customers between competitors, or bid rigging; or .
{c} For the commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.
I understand that a false statement on. this certification may be grounds for the rejection of this proposal or the termination of the award. In addition, under 18 U.S.C. §1 001, a false statement may result in a fine of up to $10,000 or imprisonment for up to five years, or both.
Name and Title of Authorized Representative
Name of Participant Agency or Firm
Signature of Authorized Representative Date
I am unable to certify to the above statement. Attached is my explanation.
File details come from the government source that posted it. Updated .