Attachment E - Federal Debarment Form.docx
DOCX document 31 KB Posted
- Attached to
- ONE-STOP OPERATOR WDA 4
- Solicitation number
- ILF0020
- Issued by
- Calumet County, Wisconsin
About this file
This document is a Federal Debarment Form (Attachment E) for RFP No. ILF0020, likely associated with a state or local government procurement process. The form is a certification document requiring vendors to disclose their legal and regulatory compliance status, specifically addressing potential exclusions, criminal convictions, pending indictments, and past transaction terminations related to federal, state, or local governmental transactions.
The certification requires vendors to attest that they and their principals have not been excluded, disqualified, convicted of specific offenses within the past three years, or terminated from public transactions. Vendors must provide their company name, an authorized representative's details, signature, and a Unique Entity Identifier (UEI) Number. The form emphasizes that false or erroneous certifications may result in potential suspension, debarment, or other remedies pursued by the federal government. The document appears to be a standard compliance requirement for entering into governmental transactions, with a revision date of 5/9/22.
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Other files
| File | Type | Posted |
|---|---|---|
| Appendix A- Statement of Work.docx | DOCX document | |
| Attachment B - Proposer Checklist.docx | DOCX document | |
| RFP Document.pdf | ||
| ADM-20022-P (R.10.2025).pdf | ||
| Attachment A - Cost Proposal.xlsx | XLSX spreadsheet | |
| Attachment C - DOA-3832 Bidder Required Form.doc | DOC document | |
| Attachment D - Disclosure of Lobbying Activities.pdf | ||
| DOA-3054 Standard Terms and Conditions.doc | DOC document | |
| DOA-3681 Supplemental Standard Terms and Conditions.doc | DOC document | |
| QA Anwsers.docx | DOCX document |
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Text version
ATTACHMENT E
RFP No.: ILF0020
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 .