Apppendix_C.pdf

WASHINGTON SUBURBAN SANITARY COMMISSION

SOLICITATION NO. 78575

Microwave Radio Repair Services

Bidders shall acknowledge receipt of this addendum in accordance with Part I, Article 8; failure to do so may result in rejection of bids.

Acknowledgment of Addenda:

Bidder’s Firm Name

By: Authorized Signature

Date:

Addendum # Dated Addendum # Dated

Addendum # Dated Addendum # Dated

Addendum # Dated Addendum # Dated

Addendum # Dated Addendum # Dated

CERTIFIED INSURANCE STATEMENT

CERTIFIED INSURANCE STATEMENT

CONTRACT NUMBER: _____________

DATE:

I certify that I will have on file within 10 days of Notice of Award, Certificates of Insurance acceptable to the

Commission, meeting all requirements set forth in the Contract Document.

Signed:

(Notary Seal)

Subscribed and sworn to before me this ____ day of ______, 20__.

Notary Public

My Commission expires _______, 20__. (Company Name & Title)

CONSENT TO USE OF ELECTRONIC SIGNATURE

Pursuant to MD Code, Commercial Law, § 21-104, each party agrees that the electronic signature of the parties included in the attached document(s) is intended to authenticate the writing(s) and shall have the same force and effect as a manually executed signature or original signature.

Pursuant to the Maryland Uniform Electronic Transactions Act, “electronic signature” means an electronic sound, symbol, or process attached to or logically associated with a record and executed or adopted by a person with the intent to sign the record. MD Code, Commercial Law, § 21-101(i). Without limitation, “electronic signature” shall also include a faxed version of an original signature, electronically scanned and transmitted version of an original signature (e.g. PDF form), or a document transmitted by electronic means and containing, or to which there is affixed, a digital signature.

Each party agrees that no certification authority or other third-party verification is necessary to authenticate the parties’ electronic signatures and that each party’s electronic signature shall be attributable to the person whose name appears below the electronic signature as the act of that person.

The parties certify that the use of electronic signatures in the attached document(s) is not for any illegal or fraudulent purpose.

Caprecia Poole-Williams Chief Procurement Officer Washington Suburban Sanitary Commission Date:

Name of Contractor:

Name of Person Signing:

Title of Person Signing:

Date:

CONTRACT CERTIFICATION AFFIDAVIT

1. I HEREBY CERTIFY that I am the (Title) and the duly authorized representative of (Name of Firm) (the “Firm”), and that I possess the legal authority to make this certification and affidavit on my own behalf and on behalf of the Firm for which I am acting.

2. BID/PROPOSAL/OFFER AFFIDAVIT

A. DEFINITIONS

As used herein, “Commission” or “WSSC” shall refer to the Washington Suburban Sanitary Commission, and “Contract” shall refer to any contract with the Commission arising out of or relating to the bid, proposal or offer for which this Contract Certification Affidavit is submitted.

B. CERTIFICATION AND AFFIRMATION REGARDING COMMERCIAL NONDISCRIMINATION

The Firm hereby certifies and agrees that the following information is correct: In preparing its bid, proposal, of offer, it has considered all proposals submitted from qualified, potential subcontractors and suppliers, and has not engaged in “discrimination” as defined in §19-103 of the State Finance and Procurement Article of the Annotated Code of Maryland. “Discrimination” means any disadvantage, difference, distinction, or preference in the solicitation, selection, hiring, or commercial treatment of a vendor, supplier subcontractor, or commercial customer on the basis of race, color, religion, ancestry, or national origin, sex, age, marital status, sexual orientation, or on the basis of disability or any otherwise unlawful use of characteristics regarding the vendor’s, supplier’s, or commercial customer’s employees or owners. “Discrimination” also includes retaliating against any person or other entity for reporting any incident of “discrimination”. Without limiting any other provision of the solicitation on this project, it is understood that, if the certification is false, such false certification constitutes grounds for the Commission to reject the bid, proposal or offer submitted by the Firm, and terminate any contract awarded based on the bid, proposal or offer. As part of its bid, proposal, or offer, the Firm herewith submits a list of all instances within the immediate past 4 years where there has been a final adjudicated determination in a legal or administrative proceeding in the State of Maryland that the Firm discriminated against its subcontractors, vendors, suppliers, or commercial customers, and a description of the status or resolution of that complaint, including any remedial action taken. The Firm agrees to comply in all respects with the Commission’s Nondiscrimination Policy as referenced in Chapter 6.30.020 of the WSSC Code of Regulations, the Nondiscrimination Policy set forth in §17-402.1 of the Public Utilities Article of the Annotated Code of Maryland, and the Commercial Nondiscrimination Policy as described under Title 19 of the State Finance and Procurement Article of the Annotated Code of Maryland.

B-1. Certification Regarding Minority Business Enterprises.

The Firm hereby certifies and agrees that it has fully complied with the State Minority Business Enterprise Law, State Finance and Procurement Article, §14-308(a)(2), Annotated Code of Maryland, which provides that, except as otherwise provided by law, a contractor may not identify a certified minority business enterprise in a bid or proposal and:

(1) Fail to request, receive, or otherwise obtain authorization from the certified minority business enterprise to identify the certified minority enterprise in its bid or proposal;

(2) Fail to notify the certified minority business enterprise before execution of the contract of its inclusion in the bid or proposal;

(3) Fail to use the certified minority business enterprise in the performance of the contract; or

(4) Pay the certified minority business enterprise solely for the use of its name in the bid or proposal.

Without limiting any other provision of the solicitation on this project, it is understood that if the certification is false, such false certification constitutes grounds for the Commission to reject the bid submitted by the bidder on this project, and terminate any contract awarded based on the bid.

C-2. Certification Regarding Veteran-Owned Small Business Enterprises. The undersigned bidder hereby certifies and agrees that it has fully complied with the State veteran-owned small business enterprise law, State Finance and Procurement Article, §14-605, Annotated Code of Maryland, which provides that a person may not:

(1) Knowingly and with intent to defraud, fraudulently obtain, attempt to obtain, or aid another person in fraudulently obtaining or attempting to obtain public money, procurement contracts, or funds expended under a procurement contract to which the person is not entitled under this title;

(2) Knowingly and with intent to defraud, fraudulently represent participation of a veteran owned small business enterprise in order to obtain or retain a bid preference or a procurement contract;

(3) Willfully and knowingly make or subscribe to any statement, declaration, or other document that is fraudulent or false as to any material matter, whether or not that falsity or fraud is committed with the knowledge or consent of the person authorized or required to present the declaration, statement, or document;

(4) Willfully and knowingly aid, assist in, procure, counsel, or advise the preparation or presentation of a http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS19-103&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS19-103&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS14-308&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=SP&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search)&co_pp_d86d0000be040 http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS14-605&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS14-605&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) declaration, statement, or other document that is fraudulent or false as to any material matter, regardless of whether that falsity or fraud is committed with the knowledge or consent of the person authorized or required to present the declaration, statement, or document;

(5) Willfully and knowingly fail to file any declaration or notice with the unit that is required by COMAR 21.11.12; or

(6) Establish, knowingly aid in the establishment of, or exercise control over a business found to have violated a provision of §B-2(1)-(5) above.

C. AFFIRMATION REGARDING BRIBERY CONVICTIONS

I FURTHER CERTIFY AND AFFIRM THAT:

Neither I, nor to the best of my knowledge, information, and belief, the Firm (as is defined in Section 16-101(b) of the State Finance and Procurement Article of the Annotated Code of Maryland), or any of its officers, directors, partners, controlling stockholders, or any of its employees directly involved in the business’s contracting activities including obtaining or performing contracts with public bodies has been convicted of, or has had probation before judgment imposed pursuant to Criminal Procedure Article, §6-220, Annotated Code ofMaryland, or has pleaded nolo contendere to a charge of, bribery, attempted bribery, or conspiracy to bribe in violation of Maryland law, or of the law of any other state or federal law, except as follows (indicate the reasonswhy the affirmation cannot be given and list any conviction, plea, or imposition of probation before judgment with the date, court, official or administrative body, the sentence or disposition, the name(s) of person(s) involved, and their current positions and responsibilities with the business):

D. AFFIRMATION REGARDING OTHER CONVICTIONS

Neither I, nor to the best of my knowledge, information, and belief the Firm, nor any business related by common ownership or management control to the Firm (including subsidiaries, affiliates, or parent corporations), nor any of their respective officers, directors, partners, principals, members, controlling stockholders, or employees directly involved in the business’s contracting activities including obtaining or performing contracts with public bodies, has:

(1) Been convicted under state or federal statute of:

(a) A criminal offense incident to obtaining, attempting to obtain, or performing a public or private contract;

or

(b) Fraud, embezzlement, theft, forgery, falsification, or destruction of records or receiving stolen property;

(2) Been convicted of any criminal violation of a state or federal antitrust statute;

(3) Been convicted under the provisions of Title 18 of the United States Code for violation of the Racketeer Influenced and Corrupt Organization Act, 18 U.S.C. §1961 et seq., or the Mail Fraud Act, 18 U.S.C. §1341 et seq., for acts in connection with the submission of bids or proposals for a public or private contract;

(4) Been convicted of a violation of the State Minority Business Enterprise Law, §14-308 of the State Finance and Procurement Article of the Annotated Code of Maryland;

(5) Been convicted of a violation of §11-205.1 of the State Finance and Procurement Article of the Annotated Code of Maryland;

(6) Been convicted of conspiracy to commit any act or omission that would constitute grounds for conviction or liability under any law or statute described in subsections (1)-(5) above;

(7) Been convicted of a violation of one or more of the following provisions of the Internal Revenue Code:

(a) §7201. Attempt to Evade or Defeat Tax

(b) §7203. Willful Failure to File Return, Supply Information, or Pay Tax

(c) §7205. Fraudulent Withholding Exemption Certificate or Failure to Supply Information

(d) §7206. Fraud and False Statements or

(e) §7207. Fraudulent Returns, Statements or Other Documents.

(8) Been convicted of a violation of one or more of the following provisions of the United States Code:

http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS16-101&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=SP&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search)&co_pp_a83b000018c76 http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS16-101&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=SP&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search)&co_pp_a83b000018c76 http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS16-101&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=SP&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search)&co_pp_a83b000018c76 http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1016763&cite=MDCPCS6-220&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000546&cite=18USCAS1961&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000546&cite=18USCAS1341&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000546&cite=18USCAS1341&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS14-308&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS14-308&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS11-205.1&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search)

(a) 18 U.S.C. §286. Conspiracy to Defraud the Government with Respect to Claims

(b) 18 U.S.C. §287. False, Fictitious, or Fraudulent Claims, or

(c) 18 U.S.C. §371. Conspiracy to Defraud the United States

(9) Been convicted of a violation of Title 13, Subtitle 7, or Title 13, Subtitle 10, of the Tax-General Article of the

Annotated Code of Maryland.

(10) Been found to have willfully or knowingly violated Title 17, Subtitle 2 (Prevailing Wage Law), or Title 18 (State Living Wage Law) of the State Finance & Procurement Article of the Annotated Code of Maryland if:

(i) the finding was made by a court and the decision of the court became final, or

(ii) the finding was made in a contested case under the Administrative Procedure Act and the finding was not overturned on judicial review;

(11) Been found to have willfully or knowingly violated Title 3, Subtitle 3 (Equal Pay for Equal Work), Subtitle

4 (Wage and Hours), or Subtitle 5 (Wage Payment and Collection) or Title 5 (Occupational Health & Safety) of the Labor and Employment Article of the Annotated Code of Maryland if:

(i) the finding was made by a court and the decision of the court became final; or

(ii the finding was made in a contested case under the Administrative Procedure Act and the finding was not overturned on judicial review;

(12) Been convicted of making a payment of a gratuity to, or supplementing the salary of, a public official or similar offenses relating to public graft;

(13) Been found civilly liable under a state or federal antitrust statute for acts or omissions in connection with thesubmission of bids or proposals for a public or private contract;

(14) Been found in a final adjudicated decision to have violated the Commercial Nondiscrimination Policy under

Title 19 of the State Finance and Procurement Article of the Annotated Code of Maryland with regard to a public or private contract; or

(15) Admitted in writing or under oath, during the course of an official investigation or other proceedings, acts or omissions that would constitute grounds for conviction or liability under any law or statute described in §§B and C and subsections D 1-14 above, except as follows:

(indicate reasons why the affirmations cannot be given, and list any conviction, plea, or imposition of probation before judgment with the date, court, official or administrative body, the sentence or disposition, the name(s) of the person(s) involved and their current positions and responsibilities with the business, and the status of any debarment):

E. AFFIRMATION REGARDING DEBARMENT

Neither I, nor to the best of my knowledge, information, and belief, the Firm, or any of its officers, directors, partners, principals, members, controlling stockholders, or any of its employees directly involved in the business’s contracting activities, including obtaining or performing contracts with public bodies, has ever been suspended or debarred (including being issued a limited denial of participation) by any public entity, except as follows:

(list each debarment or suspension providing the dates of the suspension or debarment, the name of the public entity and the status of the proceedings, the name(s) of the person(s) involved and their current positions and responsibilities with the business, the grounds of the debarment or suspension, and the details of each person’s involvement in any activity that formed the grounds of the debarment or suspension).

F. AFFIRMATION REGARDING DEBARMENT OF RELATED ENTITIES

(1) The Firm was not established and it does not operate in a manner designed to evade the application of or defeat the purpose of debarment pursuant to Sections 16-101, et seq., of the State Finance and Procurement Article of the Annotated Code of Maryland;

(2) The Firm is not a successor, assignee, subsidiary, or affiliate of a suspended or debarred business except as follows:

(you must indicate the reasons why the affirmations cannot be given without qualification):

G. SUB-CONTRACT AFFIRMATION

Neither I, nor to the best of my knowledge, information, and belief, the Firm has knowingly entered into a contract with a public body (including the Commission) under which an individual or entity debarred or suspended under Title 16 of the State Finance and Procurement Article of the Annotated Code of Maryland, or under Chapter 6.15.540 of the WSSC Code of Regulations will provide, directly or indirectly, supplies, services, architectural services, construction related services, leases of real property, or construction.

H. AFFIRMATION REGARDING COLLUSION

Neither I, nor to the best of my knowledge, information, and belief, the Firm has:

(1) Agreed, conspired, connived, or colluded to produce a deceptive show of competition in the compilation of the accompanying bid, proposal or offer that is being submitted;

(2) In any manner, directly or indirectly, entered into any agreement of any kind to fix the offer, bid price, or price proposal of the bidder, proposer, or offeror or of any competitor, or otherwise taken any action in restraint of free competitive bidding in connection with the contract for which the accompanying bid, proposal or offer is submitted; or

(3) Acted in collusion with another individual, partnership, firm, association, corporation, or entity in violation of § 11-205 of the State Finance & Procurement Article of the Annotated Code of Maryland.

I. CERTIFICATION OF TAX PAYMENT

I FURTHER CERTIFY AND AFFIRM THAT: Except as validly contested, the Firm has paid, or has arranged for payment of, all taxes due the State of Maryland and has filed all required returns and reports with the Comptroller of the Treasury, the State Department of Assessments and Taxation, and the Department of Labor, Licensing, and Regulation, as applicable, and will have paid all withholding taxes due the State of Maryland prior to final settlement.

J. CONTINGENT FEES

The Firm has not employed or retained any person, partnership, firm, association, corporation, or other entity, other than a bona fide employee, bona fide agent, bona fide salesperson, or commercial selling agency working for the Firm, to solicit or secure the Contract, and that the Firm has not paid or agreed to pay any person, partnership, firm, association, corporation, or other entity, other than a bona fide employee, bona fide agent, bona fide salesperson, or commercial selling agency, any fee or any other consideration contingent on the award of making of the Contract.

ACKNOWLEDGEMENT

I ACKNOWLEDGE THAT this Affidavit is to be furnished to the Commission and its Procurement Officer and may be distributed to units of: (1) the State of Maryland; (2) counties or other subdivisions of the State of Maryland;

(3) other states; and (4) the federal government. I further acknowledge that this Affidavit is subject to applicable laws of the United States and the State of Maryland, both criminal and civil, and that nothing in this Affidavit or any contract resulting from the submission of this bid, proposal or offer shall be construed to supersede, amend, modify or waive, on behalf of the Commission, the State of Maryland, or any unit of the State of Maryland having http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS16-101&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) http://www.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000031&cite=MDSFAPS16-101&originatingDoc=I5F872C20B7FC11DF9381B7F57A7FEE4E&refType=LQ&originationContext=document&vr=3.0&rs=cblt1.0&transitionType=DocumentItem&contextData=(sc.Search) jurisdiction, the exercise of any statutory right or remedy conferred by the Constitution and the laws of Maryland with respect to any misrepresentation made or any violation of the obligations, terms and covenants undertaken by the Firm with respect to (1) this Affidavit, (2) the Contract, and (3) other Affidavits comprising part of the Contract.

ADDITIONAL CERTIFICATIONS AND AFFIRMATIONS

3. I HEREBY FURTHER CERTIFY that to the best of my knowledge and belief, the cost or pricing data submitted in support of the bid, proposal or offer submitted herewith are current, accurate and complete.

4. I FURTHER CERTIFY that this Firm is a Minority Business Enterprise as defined by the Commission's Code of Regulations as follows:

(If the Firm is a Minority Business Enterprise, please complete this certification. If the Firm is not a Minority Business Enterprise, please check here .)

Minority Group(s) Represented:

Percent of Minority Ownership and Control:

%Certifying Agency:

Certification No:

County/State:

The Bidder must attach a copy of the minority certification to its Bid, Proposal or Offer.

5. I FURTHER CERTIFY that this firm, its officers, directors, partners and employees, and the representative agent agrees to abide by the Article "Ethics in Public Contracting" of the WSSC's Code of Ethics.

6. I FURTHER CERTIFY that this Firm qualifies as a Small Local Business Enterprise (SLBE) as defined by the Commission’s Code of Regulations and has a principal place(s) of business or significant employment presence in Prince George’s County or Montgomery County as follows:

(If the Firm does qualify, please complete this certification. If the Firm does not qualify as a SLBE, please check here .)

Type of Facility Type of Facility

Street Address Street Address

City, County City, County

Telephone Number Telephone Number

WITHOUT LIMITING ANY OTHER PROVISION OF THE SOLICITATION WHICH IS THE SUBJECT OF THIS CERTIFICATION AND AFFIDAVIT, IT IS ACKNOWLEDGED AND UNDERSTOOD THAT IF ANY OF THE STATEMENTS OR REPRESENTATIONS IN THIS CERTIFICATION AND AFFIDAVIT ARE NOT TRUE AND CORRECT, THE COMMISSION MAY, IN ADDITION TO ANY OTHER REMEDIES AVAILABLE UNDER THE LAW, REJECT THE BID, PROPOSAL OR OFFER SUBMITTED BY THE FIRM; TERMINATE ANY CONTRACT

AWARDED BASED ON THE BID, PROPOSAL OR OFFER; AND/OR TAKE ANY OTHER APPROPRIATE ACTION.

I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT THE CONTENTS OF THIS

CERTIFICATION AND AFFIDAVIT ARE TRUE AND CORRECT.

DATE:

BY:

SIGNATURE

PRINTED NAME/TITLE:

NAME OF FIRM:

FIRM'S EMPLOYER IDENTIFICATION NO.:

FIRM’S TELEPHONE NO.:

FIRM’S FACSIMILE NO.:

FIRM’S E-MAIL ADDRESS:

Subscribed and sworn to before me this day of , 20 .

Notary Public

My commission expires:

Revised 02/02/24

IRAN INVESTMENT ACTIVITY CERTIFICATION

I ____________________________(Name) hereby certify that I am the

_________________________(Title) of __________________________ (“Firm”), and am duly authorized to make the following certifications on behalf of the Firm:

1) I HEREBY CERTIFY, that the Firm is not identified on the list created by the Maryland Board of Public Works as a person or entity engaging in investment activities in Iran as described in State Finance and Procurement Article, §17- 702 Annotated Code of Maryland.

2) I HEREBY CERTIFY, that the firm is not engaging in investment activities in Iran as described in State Finance and Procurement Article, §17-702 Annotated Code of Maryland.

I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF

PERJURY THAT THE CONTENTS OF THIS CERTIFICATION ARE TRUE

AND CORRECT

SIGNATURE DATE

PRINTED NAME: _______________________________________

TITLE:______________________________

NAME OF FIRM: ___________________________________

FIRM EMPLOYER IDENTIFICATION NO.: __________________

TELEPHONE: ________________________

FACSIMILE: _________________________

EMAIL: _____________________________

Subscribed and sworn to before me this _______ day of _____________, 20___.

_________________________________(SEAL)

Notary Public My Commission expires:

SIGNATURE PAGE

The General and Special Conditions included or referenced in this Solicitation shall be incorporated in any resulting Contract by reference and shall become a part of said

Contract.

Submission of the Bid/Proposal shall be considered as prima facie evidence that the

Bidder/Offeror has familiarized himself with and understands the conditions under which the

Contract will be awarded, performed and administered.

Name of Bidder/Offeror must be shown in full if an individual; and if a partnership, full names of all partners must be shown. If Bidder/Offeror is a corporation, impress corporate seal and furnish name of state where incorporated. If joint venture, all parties must sign. If limited liability company, the managing member must sign and furnish the state of organization.

Bidder/Offeror represents that his firm does business as (check one) ____ an individual, ____ a partnership, ____ a joint venture, ____ limited liability company or ____ a corporation. The Bidder/Offeror hereby agrees that if accepted by the Commission he will well and faithfully perform as specified.

Incorporated in the State of ___________

Accepted this date __________________ for the WASHINGTON SUBURBAN

SANITARY COMMISSION

Signature / Acquisition Director

WITNESS:

Signature

Firm’s Telephone No.: ______________________

Name of Bidder / Offeror (type or print)

Signature

Printed Name and Title

Business address (type or print)

WITNESS / ATTEST:

Signature