Attachment_7_-_Iran_Contracting_Act_Verification.pdf
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- Attached to
- RFP-AIC-25-003 (Arts in Corrections
- Solicitation number
- 0000037096
- Issued by
- Sacramento County, San Francisco City, California
About this file
This document is the Iran Contracting Act Verification Form (DGS PD 3) issued by the California Department of General Services, Procurement Division, required for State of California contract opportunities.
The form applies to vendors seeking to bid on, submit proposals for, or execute State of California contracts for goods or services valued at $1,000,000 or more. Vendors must complete this certification prior to bidding and must verify compliance with Public Contract Code sections 2202-2208. The form requires vendors to insert their name and Federal ID Number and complete one of two 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 to another person for 45 days or more if that credit will be used to provide goods or services in Iran's energy sector. Option #2 permits vendors to demonstrate they have obtained an exemption from the certification requirement under Public Contract Code sections 2203(c) or (d) on a case-by-case basis, with documentation of exemption approval required.
California law establishes substantial 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 state contracts. The authorized signatory must certify they are duly authorized to execute the form on behalf of the vendor or financial institution. The DGS maintains a current list of ineligible businesses on its website, which vendors must reference before submitting their certification.
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Text version
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 (https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division- Resources-List-Folder/List-of-Ineligible-Businesses#@ViewBag.JumpTo)
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) https://www.dgs.ca.gov/PD/Resources/Page-Content/Procurement-Division-Resources-List-Folder/List-of-Ineligible-Businesses#@ViewBag.JumpTo 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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