Attachment 12 - Self Certification for Antimafia Communication.pdf

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Maintenance and Repair of Dehumidification Plants at Leghorn Army Depot, DMC, USAG Italy
Solicitation number
W912PF24Q0096
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The document provided is a self-certification for Antimafia communication, which is a declaration of the absence of certain prohibitions, disqualifications or suspensions for the signatory.

The related federal contract opportunity is a Request for Quotation (RFQ) from the Department of the Army Materiel Command Army Contracting Command for the Maintenance and Repair of Dehumidification Plants at the Leghorn Army Depot, DMC, USAG Italy. The performance period is from August 23, 2024 to August 22, 2027, with a base year and two option years. This is a hybrid Firm-Fixed Price and Time and Material type contract. Prospective contractors must have a NCAGE number and be registered in the System for Award Management (SAM) website to be awarded the contract. A pre-quote conference will be held on July 9, 2024. The due date for submitting the quotation is not provided in the information given.

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Self-certification for Antimafia communication

Autocertificazione della comunicazione antimafia

Dichiarazione sostitutiva di certificazione (D.P.R. n. 445 del 28.12.2000)

Il/la sottoscritto/a (nome e cognome) _______________________________ C.F._________________ nato/a _______________________________ Prov. _________ il ______________ residente a

________________________ Prov. _____ in via/piazza ____________________

_______________________________ n. ____, in qualità di (carica ricoperta) ___________ dell’impresa (indicare la denominazione) _______________________________________________ C.F. __________________ avente la sede in _________________________ Prov. di __________ Via ___________________________ n. ______ consapevole delle sanzioni penali in caso di dichiarazioni false e della conseguente decadenza dai benefici eventualmente conseguiti (ai sensi degli artt. 75 e 76 D.P.R. 445/2000) sotto la propria responsabilità

DICHIARA

che nei propri confronti non sussistono le cause di divieto, di decadenza o di sospensione di cui all’art. 67 del D.lgs. n. 159 del 06/09/2011.

Il/la sottoscritto/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di dati personali) che i dati personali raccolti saranno trattati, anche con strumenti informatici, esclusivamente nell’ambito del procedimento per il quale la presente dichiarazione viene resa.

data firma leggibile del dichiarante (2)

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