Attachment_4_-_General_Certifications_Form.docx
DOCX document 28 KB Posted
- Attached to
- RFP 25-02 Life Insurance Benefit Plans
- Solicitation number
- 0000036099
- Issued by
- San Bernardino County, California
About this file
This document is a General Certifications Form for RFP 25-02 Life Insurance, issued by a California Court system. The form requires bidders to certify compliance with several key legal and regulatory requirements, including conflict of interest regulations, suspension/debarment status, tax delinquency, and conflict minerals provisions.
The certification form mandates that bidders attest to their eligibility by confirming they are not suspended or debarred from state contracting, are not on tax delinquency lists, and are not considered "scrutinized companies" under specific securities regulations. Bidders must sign the document, indicating their authorization to legally bind their company, and provide company details, signature, execution date, and the printed name and title of the authorized signatory. The form appears to be a mandatory attachment for bid submission, with the Court explicitly stating that bids without this properly completed form will be rejected.
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Text version
RFP 25-02 Life Insurance
ATTACHMENT 4
GENERAL CERTIFICATIONS FORM
Read the following clauses carefully. If agreed, sign this attachment and return with your bid or proposal. Please note that the Court will reject any bid or proposal that does not include this properly completed and signed attachment.
Conflict of Interest. Bidder has no interest that would constitute a conflict of interest under California Public Contract Code (PCC) sections 10365.5, 10410 or 10411; Government Code sections 1090 et seq. or 87100 et seq.; or California Rules of Court, rule 10.103 or 10.104, which restrict employees and former employees from contracting with judicial branch entities.
Suspension or Debarment. Bidder certifies that neither Bidder nor any of Bidder’s intended subcontractors is on the California Department of General Services’ list of firms and persons that have been suspended or debarred from contracting with the state because of a violation of PCC 10115.10, regarding disabled veteran business enterprises.
Tax Delinquency. Bidder certifies that it is not on either (i) the California Franchise Tax Board’s list of 500 largest state income tax delinquencies, or (ii) the California Board of Equalization’s list of 500 largest delinquent sales and use tax accounts.
Conflict Minerals. Bidder certifies that either (i) it is not a scrutinized company as defined in PCC 10490(b), or (ii) the goods or services the Bidder would provide to the Court are not related to products or services that are the reason the Bidder must comply with Section 13(p) of the Securities Exchange Act of 1934. (Note: PCC 10490(b) defines a “scrutinized company” as “a person that has been found to be in violation of Section 13(p) of the Securities Exchange Act of 1934 by final judgment or settlement entered in a civil or administrative action brought by the Securities and Exchange Commission and the person has not remedied or cured the violation in a manner accepted by the commission on or before final judgment or settlement.”)
By signing below, signer indicates acceptance of the clauses above on behalf of Bidder and certifies they are duly authorized to legally bind the Bidder:
Legal Name of Company (Printed):
| Signature: |
| Date Executed: |
Printed Name and Title of Person Signing:
Rev. 2020-07 Page 1 of 1
File details come from the government source that posted it. Updated .