Attachment E - Federal Debarment Form.docx
DOCX document 31 KB Posted
- Attached to
- ONE-STOP OPERATOR WDA 8
- Solicitation number
- ILG0007
- Issued by
- Ashland County, Wisconsin
About this file
This is a Federal Debarment Form (Attachment E) required for the One-Stop Operator WDA 8 Request for Proposals (RFP No. ILG0007) issued by the Wisconsin Department of Workforce Development (DWD) on behalf of the West Central Wisconsin Workforce Development Board (WCWWDB). The form serves as a certification document that applicants must complete and submit as part of their proposal to retain an One-Stop Operator to coordinate service delivery across required one-stop partners and service providers. The contract will be a single award executed and administered by either WCWWDB or a designated Contracting Entity, with no guarantee of specific service quantities or dollar amounts.
The debarment certification requires the duly authorized representative of the applicant to certify that neither the applicant nor its principals are presently excluded or disqualified from federal transactions, have been convicted of specified offenses within the preceding three years, are currently indicted or charged with such offenses, or have had public transactions terminated for cause or default within the preceding three years. Applicants must provide their company name, authorized representative name and title, signature, date, and Unique Entity Identifier (UEI) number. Submission of an erroneous certification constitutes a material misrepresentation of fact and may result in suspension, debarment, or other remedies available to the federal government. Applicants are required to provide immediate written notice if the certification becomes erroneous at any time after submission.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Appendix A- Statement of Work.docx | DOCX document | |
| DOA-3681 Supplemental Standard Terms and Conditions.pdf | ||
| RFP Document.pdf | ||
| Attachment A - Cost Proposal.xlsx | XLSX spreadsheet | |
| ADM-20022-P (R.10.2025).pdf | ||
| DOA-3054 Standard Terms and ConditionsRFB-RFP.pdf | ||
| Attachment C - DOA-3832 Bidder Required Form.doc | DOC document | |
| Attachment D - Disclosure of Lobbying Activities.pdf | ||
| Attachment B - Proposer Checklist.docx | DOCX document |
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Text version
ATTACHMENT E
RFP No.: ILG0007
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 .