Attachment 4 Self Certification for Antimafia Communication Tech. Assistance Water Sewage Treatment Plant.pdf
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- Solicitation number
- W912PF25QTREA
About this file
This document is a Self-certification for Antimafia Communication form associated with the U.S. Army's solicitation W912PF25QTREA for technical assistance on water and sewage treatment systems at Camp Darby and Depot in Italy. The form is a standard Italian legal declaration where the signatory attests that they do not have any disqualifying connections to criminal organizations, in compliance with Italian legal requirements (D.P.R. n. 445 del 28.12.2000). The form requires the individual to provide personal details, company information, and signature, while acknowledging potential legal penalties for false statements and consent for personal data processing.
The form is an attachment to a solicitation for a single-award, non-personal service contract for water treatment plant maintenance, with the contractor responsible for inspecting, testing, and calibrating potable water treatment and water osmosis systems. The contract specifies that 100% of the work must be performed by the contractor's own workforce, with limited exceptions for specialized technical assistance from authorized service centers. The solicitation is structured as a full and open competition under NAICS code 221310 for Water Supply and Irrigation Systems, with services to be performed in accordance with current laws and norms as detailed in the associated Performance Work Statement.
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TREA
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)
File details come from the government source that posted it. Updated .