Attachment E - Federal Debarment Form.docx
DOCX document 31 KB Posted
- Attached to
- ONE-STOP OPERATOR WDA 4
- Solicitation number
- ILF0014
- Issued by
- Calumet County, Wisconsin
About this file
This document is a Federal Debarment Certification Form for RFP No. ILF0014, likely issued by a state or local government agency (potentially the Department of Workforce Development based on the "DWD USE ONLY" notation). The form requires potential contractors to certify their legal and ethical standing before entering into a government transaction, specifically affirming that they have not been excluded, disqualified, convicted of specified offenses, or terminated from previous public transactions within the past three years.
The certification requires contractors to provide their company/organization name, an authorized representative's details, signature, date, and unique entity identifier (UEI) number. The form emphasizes that providing false or erroneous certification can result in potential suspension or debarment, and contractors are obligated to immediately notify the issuing agency if their certification status changes. While the document does not specify contract value, scope, or specific services, it represents a critical compliance document for government contracting that ensures vendor responsibility and ethical standards.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment C - DOA-3832 Bidder Required Form.doc | DOC document | |
| RFP Document.pdf | ||
| ADM-20022-P.docx | DOCX document | |
| Appendix A- Statement of Work.docx | DOCX document | |
| Attachment B - Proposer Checklist.docx | DOCX document | |
| DOA-3681 Supplemental Standard Terms and Conditions.doc | DOC document | |
| Attachment D - Disclosure of Lobbying Activities.pdf | ||
| Attachment A - Cost Proposal.xlsx | XLSX spreadsheet | |
| DOA-3054 Standard Terms and Conditions.doc | DOC document |
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Text version
ATTACHMENT E
RFP No.: ILF0014
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
AND OTHER RESPONSIBILITY MATTERS
This certification is required by OMB Guidelines to Agencies on Governmentwide Debarment and Suspension (Nonprocurement), 2 CFR Part 180, Section 180.335, What information must I provide before entering into a covered transaction with a Federal agency?
As the duly authorized representative of the applicant, I certify, to the best of my knowledge and belief, that neither the applicant nor its principals:
· Is presently excluded or disqualified;
· Has been convicted within the preceding three years of any of the offenses listed in 2 CFR § 180.800(a) or had a civil judgment rendered against it for one of those offenses within that time period;
· Is presently indicted for, or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with, commission or any of the offenses listed in 2 CFR § 180.800(a); or
· Has had one or more public transactions (federal, state, or local) terminated within the preceding three years for cause or default.
Company/Organization Name
Name and Title of Authorized Representative
Signature Date
Unique Entity Identifier (UEI) Number
Other Notes and Instructions:
This certification is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that you knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
You shall provide immediate written notice to the person to whom this proposal is submitted if at any time the applicant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
DWD USE ONLY
Contract No.:
rev. 5/9/22
File details come from the government source that posted it. Updated .