Attachment 3 to ITB 2025-1000-0200 - Certification Regarding Debarment.pdf
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- Attached to
- Invitation to Bid (ITB) 2025-1000-0200 As-Needed Silviculture Services Near Haines, Alaska
- Solicitation number
- Invitation to Bid (ITB) 2025-1000-0200 As-Needed S
- Issued by
- Dillingham Census Area, Alaska
About this file
This is Attachment 3, a Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion form for Lower Tier Covered Transactions, required as part of ITB 2025-1000-0200 for As-Needed Silviculture Services near Haines, Alaska issued by the State of Alaska. The certification form implements Executive Order 12549 and requires prospective recipients of federal assistance funds to certify that neither they nor their principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation by any Federal department or agency.
The form requires companies to be enrolled in the Federal System for Awards Management (SAM) before a contract can be signed or payment made on a contract involving federal funds. Companies must provide either their DUNS Number or Cage Code if enrolled in SAM. Failure to enroll in SAM will result in cancellation of the contract. The form requires signature from an authorized representative, including their name, title, and date of certification.
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Text version
STATE OF ALASKA – INVITATION TO BID (ITB) ITB 2025-1000-0200
AS-NEEDED SILVICULTURE SERVICES NEAR HAINES, ALASKA
PAGE 47 OF 56 REV. 11/24
ATTACHMENT 3
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY,
AND VOLUNTARY EXCLUSION
LOWER TIER COVERED TRANSACTIONS
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participant's responsibilities.
The regulations were published as Part VII of the May 26, 1988, Federal Register (pages 19160-19211).
(BEFORE COMPLETING CERTIFICATION, READ THE INSTRUCTIONS ON THE
FOLLOWING PAGE WHICH ARE AN INTEGRAL PART OF THE CERTIFICATION)
The prospective recipient of federal assistance funds certifies, by submission of this bid, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
Where the prospective recipient of federal assistance funds is unable to certify to any of the Statements in this certification, such prospective participant shall attach an explanation to this bid.
Name of Representative: ________________________________________________________________.
Title of Representative: __________________________________________________________________.
Signature: _______________________________________________________________________________.
Date: ___________________________________________________________________________________.
1. Is this company enrolled in the Federal System for Awards Management (SAM)? YES NO
2. If Yes, please provide either the DUNS Number ______________________________________ or the Cage Code _________________________________________.
3. If No, the company must be enrolled in SAM before a contract can be signed or payment made on a contract involving federal funds. Failure to do so will result in cancellation of the contract.
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