Appendix D - Debarment Form.pdf
PDF 38 KB Posted
- Attached to
- Traffic Signal Modernization - Engineering Services State and local contract opportunity
- Solicitation number
- 37-25-037
- Issued by
- Wayne County, Michigan
About this file
This document is a Certification Regarding Debarment, Suspension, and Other Responsibility Matters form for a participant in a state and local contract opportunity related to the County of Wayne's Traffic Signal Modernization project. The form requires the prospective participant to certify that they are not currently debarred, suspended, or excluded from federal, state, or local transactions, have not had public transactions terminated for cause within the past three years, and are not currently under criminal or civil charges related to fraud, antitrust violations, or other specified offenses.
The certification carries significant legal implications, with potential consequences including proposal rejection, contract termination, and legal penalties under 18 U.S.C. §1001, which could result in fines up to $10,000 or imprisonment for up to five years for false statements. The form provides a checkbox for participants who are unable to certify the statement, requiring them to attach an explanation. This document is part of the procurement process for the Wayne County Traffic Signal Modernization project, which is funded through the FY 2026 Highway Safety Improvement plan.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Appendix C - DBE Form - 37-25-037.pdf | ||
| Appendix A - Price Sheet.xlsx | XLSX spreadsheet | |
| RFP 37-25-037 - Traffic Signal Design.docx | DOCX document | |
| First Tier Subcontractor_designation_form-final 8-2023.pdf | ||
| W-9 Form v10-18.pdf | ||
| attachment-download.doc | DOC document |
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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 .