Attachment D Vendor Certification_.pdf
PDF 28 KB Posted
- Solicitation number
- RFP GIS 210000001110 1
- Issued by
- Genesee County, Michigan
About this file
This is a vendor certification form required by the Genesee Intermediate School District located in Flint, Michigan, for compliance with the Iran Economic Sanctions Act (Public Act 517 of 2012). The document serves as a binding certification that bidders must complete and have notarized before submitting bids for services to the school district. Bidders are required to certify that they are not Iran-linked businesses as defined under MCL 129.311, et seq., and that they have personal knowledge of the matters described in the certification. The form requires bidders to provide their organization name, address, contact number, and the name and title of the person authorized to bind the contractor or vendor.
Submission of this completed and notarized certification is mandatory; bids without this sworn and notarized certification will not be accepted. Bidders must understand that submission of false certification carries significant penalties, including contract termination, ineligibility to bid for three years, and a civil penalty of $250,000 or twice the bid amount, whichever is greater, plus investigation and legal costs. The form requires notarization before a Notary Public, who must acknowledge the bidder's signature and provide their own signature, commission expiration date, and acting county information.
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Text version
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 Click here to enter text of Click here to enter text, or I am bidding in my individual capacity ("Bidder"), with authority to submit a binding bid for the provision of Click here to enter text. 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 sworn and notarized 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
Seal:
This instrument was acknowledged before me, a Notary Public, in and for ___________________________ County, _____________________ on this _________ day of ________________________, 20_________.
State
Notary Public Signature Date
My Commission Expires: _______________________
Acting in the County of: ________________________
Attachment D
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Attachment D Vendor Certification_.pdf
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