Attachment J.5 Certificate of Eligibility.pdf
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- Attached to
- BANKING AND DEPOSIT SERVICES & DISBURSEMENTS
- Solicitation number
- DCSC-25-RFP-127
- Issued by
- District of Columbia Government
About this file
Attachment J.5 is a Certification of Eligibility form used to verify a contractor's legal and financial standing for a federal contract. The document requires the contractor to certify that neither the company nor any associated personnel are currently under suspension, debarment, or ineligibility by any Federal, District, or State agency. The certification covers a three-year lookback period and requires disclosure of any past suspensions, debarments, indictments, convictions, or civil judgments involving fraud or official misconduct. The form includes spaces for the contractor's name, signature, date, title, and requires notarization, with a warning that providing false information may result in criminal prosecution or administrative sanctions under the Program Fraud Civil Remedies Act of 1986.
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Text version
ATTACHMENT J.5
CERTIFICATION OF ELIGIBILITY
PROJECT NAME: ______________________________________________________________
__________________________________________________________, being duly sworn, or under penalty of perjury under the laws of the United States, certifies that, except as noted below, (the company) or any person associated therewith in the capacity of (owner, partner, director, officer, principal investigator, project director, manager, auditor, or any position involving the administration of federal funds) is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility under any Federal, District or State statutes; has not been suspended, debarred voluntarily excluded or determined ineligible by any Federal, District, or Stage agency within the past three (3) years; does not have a proposed debarment pending; and has not been indicted, convicted; or has a Civil judgment rendered against it by a Court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years.
Exceptions will not necessarily result in denial of award, but will be considered in determining bidder responsibility. For any exception noted, indicate below to whom it applies, initiating agency, and dates of action. Providing false information may result in criminal prosecution or administrative sanctions.
Contractor
Date
President or Authorized Official
Title
The penalties for making false statements are prescribed in the Program Fraud Civil Remedies Act of
1986 (Public Law 99-509, 31 U.S.C. 3801-3812).
Subscribed and sworn before me this ________ day of _____________________, 20_____, in
City and State
Notary Seal
Notary Public
File details come from the government source that posted it. Updated .