Attachment D Iran Economic Sanctions Act Certification.pdf

Attachment D

GENESEE INTERMEDIATE SCHOOL DISTRICT

ERWIN L. DAVIS EDUCATION CENTER

2413 WEST MAPLE AVENUE

FLINT, MI 48507-3493

PUBLIC ACT 517 OF 2012

IRAN ECONOMIC SANCTIONS ACT CERTIFICATION

I am the __________________of __________________, or I am bidding in my individual capacity ("Bidder"), with authority to submit a binding bid for the provision of __________________services to Genesee Intermediate School District. I have personal knowledge of the matters described in this Certification, and I am familiar with the Iran Economic Sanctions Act, MCL 129.311, et seq. ("Act"). I am fully aware that the school district will rely on my representations in evaluating bids.

I certify that Bidder is not an Iran-linked business, as that term is defined in the Act. I understand that submission of a false certification may result in contract termination, ineligibility to bid for three (3) years, and a civil penalty of $250,000 or twice the bid amount, whichever is greater, plus related investigation and legal costs.

Any bids that do not include this Certification shall not be accepted.

Owner Name & Address:

Genesee Intermediate School District 2413 West Maple Avenue

Flint, MI 48507-3493

Contractor/Vendor/Respondent Information:

Name: ______________________________________________________________________

Address: ____________________________________________________________________

( )Contact Number: ______________________________________________________________

Person Authorized to Bind the Contractor/Vendor/Respondent:

Print Name Title

Signature Date

Accessibility Report

Filename:

Attachment D Vendor Certification_.pdf

Report created by:

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