Attachment D - Debarment Certification.pdf
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- Solicitation number
- HE-25-615
- Issued by
- Los Angeles County, California
About this file
This document is a Debarment, Suspension, Ineligibility and Voluntary Exclusion Certification form issued by the City of Long Beach, Department of Health and Human Services. The certification applies to current and potential vendors seeking to receive federal grant funds through their business relationship with the City. By submitting a proposal, bid, or agreement, authorized representatives must certify under penalty of perjury that neither the business entity nor any principals involved in the transaction are currently under suspension, debarment, voluntary exclusion, or ineligibility determinations by any Federal department or agency. The certification requires attestation that within the three-year period preceding the bid or agreement, the vendor has not been suspended, debarred, voluntarily excluded, or declared ineligible by a federal agency; does not have a proposed debarment proceeding pending; has not been indicted, convicted, or subject to civil judgment involving fraud or official misconduct; and has not had public transactions terminated for cause or default.
If any reorganization, management turnover, or change in principals' status occurs, written notice must be submitted within 21 days. The City reserves the right to request updated versions of this certification on a routine basis. Vendors unable to certify to any statement in the certification must attach a written explanation to their applicable bid, agreement, or proposal. The form requires signature and date from an authorized representative and includes designated spaces for business/contractor/agency name, authorized representative name and title.
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Please read Acceptance of Certification and Instructions for Certification before completing
As a current or potential vendor for the City of Long Beach (City) your firm, through its business relationship with the City, may be the recipient of federal grant funds. As such, the City is required to document that neither your business entity or organization, nor any of your principals are debarred, suspended, ineligible, or have voluntarily been excluded from receiving federal grant funds. Consistent with Executive Order No. 12549 Title 2 CFR Part 180 Subpart C, all potential recipients of federal grant funds are required to comply with the requirements specified below. By submission of proposal/bid/agreement, the undersigned, under penalty of perjury, certifies that the participant, nor any of its principals in the capacity of owner, director, partner, officer, manager, or other person with substantial influence in the development or outcome of a covered transaction, whether or not employed by the participant:
Are not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any Federal department or agency;
Have not, within a three (3) year period preceding this bid/agreement/proposal, been suspended, debarred, voluntarily excluded or declared ineligible by a federal agency;
Do not presently have a proposed debarment proceeding pending;
Have not, within a three (3) year period preceding this bid/agreement/proposal, been indicted or convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct;
Have not, within a three (3) year period preceding this bid/agreement/proposal, had one or more public transactions (Federal, State, or local) terminated for cause or default.
If reorganization, management turnover, or a shift or change of principals’ status occurs, written notice must be submitted within 21 days. Subsequent disclosure of unfavorable information will be subject to thorough review and remedial action. Updated versions of this certification may be requested on a routine basis.
Where the potential prospective recipient of Federal assistance funds is unable to certify to any of the statement in this certification, such prospective participant shall attach an explanation to the applicable bid/agreement/proposal.
Business/Contractor/Agency
Name of Authorized Representative Title of Authorized Representative
Signature of Authorized Representative Date r20141001
CITY OF LONG BEACH
DEPARTMENT OF HEALTH AND HUMAN SERVICES
2525 Grand Avenue Long Beach, California 90815
ATTACHMENT
Debarment, Suspension, Ineligibility and Voluntary Exclusion Certification
| BusinessContractorAgency: |
| Name of Authorized Representative: |
| Title of Authorized Representative: |
| Date: |
File details come from the government source that posted it. Updated .