attachment_13,_dgs_pd_3_(iran_cert).pdf
PDF 686 KB Posted
- Attached to
- RFP 25-3021 - Alternative Methodology
- Solicitation number
- 0000037189
- Issued by
- California
About this file
Iran Contracting Act Verification Form
This is a compliance verification form issued by the California Department of General Services, Procurement Division, applicable to State of California contracts for goods or services valued at $1,000,000 or more under Public Contract Code sections 2202-2208. The form requires vendors and financial institutions to certify their compliance status prior to bidding, submitting proposals, or executing contracts. Vendors must either certify they are not engaged in investment activities in Iran as listed by the California Department of General Services, or demonstrate they have obtained an exemption from the certification requirement on a case-by-case basis. The form provides two completion options: Option #1 requires certification that the vendor is not on the current DGS list of persons engaged in investment activities in Iran and is not a financial institution extending $20,000,000 or more in credit for energy sector activities in Iran; Option #2 allows vendors with approved exemptions to provide documentation of exemption approval.
Vendors must provide their name, Federal ID Number (if available), and authorized signature with date. California law establishes significant penalties for false certifications, including civil penalties equal to the greater of $250,000 or twice the contract amount, contract termination, and three-year ineligibility to bid on contracts. The form references the DGS list of prohibited entities available at the Department of General Services Procurement Division website.
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(Public Contract Code sections 2202-2208)
Prior to bidding on, submitting a proposal or executing a contract or renewal for a State of California contract for goods or services of $1,000,000 or more, a vendor must either: a) certify it is not on the current list of persons engaged in investment activities in Iran created by the California Department of General Services (“DGS”) pursuant to Public Contract Code section 2203(b) and is not a financial institution extending twenty million dollars ($20,000,000) or more in credit to another person, for 45 days or more, if that other person will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by DGS; or b) demonstrate it has been exempted from the certification requirement for that solicitation or contract pursuant to Public Contract Code section 2203(c) or (d). The DGS list of entities prohibited from contracting with public entities in California per the Iranian Contracting Act, 2010, can be found at:
Department of General Services Procurement Division Iran Contracting Act List (http://www.documents.dgs.ca.gov/PD/poliproc/Iran%20Contracting%20Act%20List.pdf)
To comply with this requirement, please insert your vendor or financial institution name and Federal ID Number (if available) and complete one of the options below.
Please note: California law establishes penalties for providing false certifications, including civil penalties equal to the greater of $250,000 or twice the amount of the contract for which the false certification was made; contract termination; and three-year ineligibility to bid on contracts. (Public Contract Code section 2205.)
OPTION #1 - CERTIFICATION
I, the official named below, certify I am duly authorized to execute this certification on behalf of the vendor/financial institution identified below, and the vendor/financial institution identified below is not on the current list of persons engaged in investment activities in Iran created by DGS and is not a financial institution extending twenty million dollars ($20,000,000) or more in credit to another person/vendor, for 45 days or more, if that other person/vendor will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by
DGS.
DEPARTMENT OF GENERAL SERVICES
PRCUREMENT DIVISION
STATE OF CALIFORNIA
IRAN CONTRACTING ACT VERIFICATION FORM
DGS PD 3 (Rev. 12/19) http://www.documents.dgs.ca.gov/PD/poliproc/Iran%20Contracting%20Act%20List.pdf http://www.documents.dgs.ca.gov/PD/poliproc/Iran%20Contracting%20Act%20List.pdf http://www.documents.dgs.ca.gov/PD/poliproc/Iran%20Contracting%20Act%20List.pdf
Vendor Name/Financial Institution (Printed)
Federal ID Number (or n/a)
By (Authorized Signature)
Printed Name and Title of Person Signing
OPTION #2 – EXEMPTION
Pursuant to Public Contract Code sections 2203(c) and (d), a public entity may permit a vendor/financial institution engaged in investment activities in Iran, on a case-by-case basis, to be eligible for, or to bid on, submit a proposal for, or enters into or renews, a contract for goods and services.
If you have obtained an exemption from the certification requirement under the Iran Contracting Act, please fill out the information below, and attach documentation demonstrating the exemption approval.
Date
Vendor Name/Financial Institution (Printed) Federal ID Number (or n/a)
By (Authorized Signature)
Printed Name and Title of Person Signing
Date
| OPTION #1 - CERTIFICATION |
| OPTION #2 – EXEMPTION |
| Vendor NameFinancial Institution Printed: |
| Federal ID Number or na: |
| Printed Name and Title of Person Signing: |
| Vendor NameFinancial Institution Printed_2: |
| Federal ID Number or na_2: |
| Printed Name and Title of Person Signing_2: |
| ADA Instructions: |
| Date1: |
| Date2: |
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