Attachment-J.-Mercury-Affidavit.pdf
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- Solicitation number
- BPM054787
- Issued by
- Maryland
About this file
This is a Mercury Affidavit form required by the Maryland Insurance Administration (MIA) for submission with bids and proposals in response to their Request for Proposals for Specialty Financial Examination & Auditing Services. The affidavit, effective July 2024, requires an authorized representative of the bidding business to certify under penalty of perjury whether the products offered contain mercury. If products do contain mercury, the affiant must provide detailed information in an attachment describing the specific product or component containing mercury and the precise amount of mercury present, including the unit of measurement.
The completed affidavit must be signed by a duly authorized representative possessing legal authority to execute the document on behalf of the business and submitted with the bid or proposal. The affidavit acknowledges that it will be provided to the procurement officer and may be distributed to the State of Maryland, its counties and subdivisions, other states, and the federal government. Bidders are advised that the affidavit is subject to all applicable federal and Maryland laws and that any misrepresentation or violation of the affidavit's terms may result in civil and criminal penalties, and will not waive Maryland's statutory rights or remedies regarding contract enforcement.
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Text version
Attachment J – Mercury Affidavit Effective Date: July 2024
Attachment J. Mercury Affidavit
AUTHORIZED REPRESENTATIVE THEREBY AFFIRM THAT:
I, _______________________________ (name of affiant) am the _______________________________ (title) and the duly authorized representative of _______________________________ (name of the business). I possess the legal authority to make this affidavit on behalf of myself and the business for which I am acting.
MERCURY CONTENT INFORMATION:
The product(s) offered do not contain mercury.
OR
� The product(s) offered do contain mercury.
� In an attachment to this Mercury Affidavit:
(1) Describe the product or product component that contains mercury.
(2) Provide the amount of mercury that is contained in the product or product component. Indicate the unit of measure being used.
I ACKNOWLEDGE THAT this affidavit is to be furnished to the procurement officer and may be distributed to units of (1) the State of Maryland; (2) counties or other subdivisions of the State of Maryland; (3) other states; and (4) the federal government. I further acknowledge that this Affidavit is subject to applicable laws of the United States and the State of Maryland, both criminal and civil, and that nothing in this affidavit or any contract resulting from the submission of this Proposal shall be construed to supersede, amend, modify, or waive, on behalf of the State of Maryland, or any unit of the State of Maryland having jurisdiction, the exercise of any statutory right or remedy conferred by the Constitution and the laws of Maryland with respect to any misrepresentation made or any violation of the obligations, terms and covenants undertaken by the above business with respect to (1) this affidavit, (2) the contract, and (3) other affidavits comprising part of the contract.
I DO SOLEMNLY DECLARE AND AFFIRM UNDER THE PENALTIES OF PERJURY THAT
THE CONTENTS OF THIS AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE, INFORMATION, AND BELIEF.
___________________ By: ________________________________________________
Date Signature
Print Name: ____________________________________________________________________
Authorized Representative and Affiant
SUBMIT THIS AFFIDAVIT WITH BID/PROPOSAL
Attachment K. Mercury Affidavit
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