ARFQ bcf 16.31 mail machine.web purchasing affidavit.pdf
PDF 40 KB Posted
- Attached to
- Digital Mailing Machine for Webster County DHHR
- Solicitation number
- ARFQ 0511 BCF1600000031 1
- Issued by
- Wayne County, West Virginia
About this file
This is a Purchasing Affidavit form issued by the State of West Virginia Purchasing Division that establishes mandatory compliance requirements for all vendors and prospective vendors seeking state contracts. The affidavit mandates that no contract or renewal may be awarded to any vendor or related party that owes a debt exceeding one thousand dollars in aggregate to the state or its political subdivisions, or that is in employer default as defined by West Virginia Code 5A-3-10a. The form requires vendors' authorized signers to affirm under penalty of law that neither they nor any related parties owe prohibited debts or are in employer default status, unless the debt falls under specific exceptions such as contested taxes, workers' compensation premiums, permit fees, or environmental assessments that remain pending, or debts covered by valid payment plans where the vendor remains in compliance.
The affidavit defines "debt" as any assessment, premium, penalty, fine, tax, or other monetary obligation owed because of judgment, violation, or delinquency, including accrued interest and penalties. "Employer default" encompasses outstanding balances to workers' compensation funds, policy defaults, failure to maintain mandatory workers' compensation coverage, or failure to meet self-insured employer obligations, with exceptions for employers in good standing on repayment agreements with the Insurance Commissioner. "Related party" includes individuals or entities connected to the vendor through blood, marriage, ownership, or contract with five percent or greater interest in contract benefits or profits. All vendors must execute the affidavit before a notary public, providing their name, authorized signature, and the affiant's date, county, and state information.
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Text version
STATE OF WEST VIRGINIA
Purchasing Division
PURCHASING AFFIDAVIT
MANDATE: Under W. Va. Code §5A-3-10a, no contract or renewal of any contract may be awarded by the state or any of its political subdivisions to any vendor or prospective vendor when the vendor or prospective vendor or a related party to the vendor or prospective vendor is a debtor and: (1) the debt owed is an amount greater than one thousand dollars in the aggregate; or (2) the debtor is in employer default.
EXCEPTION: The prohibition listed above does not apply where a vendor has contested any tax administered pursuant to chapter eleven of the W. Va. Code, workers’ compensation premium, permit fee or environmental fee or assessment and the matter has not become final or where the vendor has entered into a payment plan or agreement and the vendor is not in default of any of the provisions of such plan or agreement.
DEFINITIONS:
“Debt” means any assessment, premium, penalty, fine, tax or other amount of money owed to the state or any of its political subdivisions because of a judgment, fine, permit violation, license assessment, defaulted workers’ compensation premium, penalty or other assessment presently delinquent or due and required to be paid to the state or any of its political subdivisions, including any interest or additional penalties accrued thereon.
“Employer default” means having an outstanding balance or liability to the old fund or to the uninsured employers' fund or being in policy default, as defined in W. Va. Code § 23-2c-2, failure to maintain mandatory workers' compensation coverage, or failure to fully meet its obligations as a workers' compensation self-insured employer. An employer is not in employer default if it has entered into a repayment agreement with the Insurance Commissioner and remains in compliance with the obligations under the repayment agreement.
“Related party” means a party, whether an individual, corporation, partnership, association, limited liability company or any other form or business association or other entity whatsoever, related to any vendor by blood, marriage, ownership or contract through which the party has a relationship of ownership or other interest with the vendor so that the party will actually or by effect receive or control a portion of the benefit, profit or other consideration from performance of a vendor contract with the party receiving an amount that meets or exceed five percent of the total contract amount.
AFFIRMATION: By signing this form, the vendor’s authorized signer affirms and acknowledges under penalty of law for false swearing (W. Va. Code §61-5-3) that neither vendor nor any related party owe a debt as defined above and that neither vendor nor any related party are in employer default as defined above, unless the debt or employer default is permitted under the exception above.
WITNESS THE FOLLOWING SIGNATURE:
Vendor’s Name: ___________________________________________________________________________________
Authorized Signature: ______________________________________________ Date: ___________________________
State of _____________________________
County of ______________________, to-wit:
Taken, subscribed, and sworn to before me this ___ day of ____________________________, 20___.
My Commission expires ______________________________, 20___.
AFFIX SEAL HERE NOTARY PUBLIC ____________________________________
Purchasing Affidavit (Revised 08/01/2015)
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