Attachment_Y_Contractor_Self-Certification_(V4_09.12.2024).pdf
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- Solicitation number
- DCAM-26-CS-RFP-0011
- Issued by
- District of Columbia
About this file
This is a Contractor Self-Certification form required by the District of Columbia Department of General Services for the Design-Build Services for Hendley ES Modernization project. The form requires submission of business identification information, including business name, Tax ID, and mailing address, along with the name, title, and contact information of the individual completing the certification on behalf of the business entity.
The certification mandates disclosure of all political contributions made by the business entity or its principals since November 9, 2022, to the Mayor, any mayoral candidates, affiliated political committees, constituent-service programs, the Attorney General, any Attorney General candidates, affiliated political committees, any Councilmember, any Councilmember candidates, affiliated political committees, and constituent-service programs. For each contribution disclosed, the form requires the date, amount, and recipient information, along with disclosure of whether the business held any District contracts at the time of contribution or within one year prior. The form also requires the business to certify its compliance with D.C. Official Code 1-1163.34a, including disclosure of any prior violations, current violations, and a certification that the business will not violate this code. Additionally, the form requires identification of all company principals by name and title, designation of any additional individuals authorized to modify the certification, and notarization of the completed form. The contractor must certify the accuracy and completeness of all information and acknowledge the obligation to maintain updated records.
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CONTRACTOR SELF-CERTIFICATION
Business Name* : Tax ID* :
Business Mailing Address * :
Select State/Region:_________________ Postal Code:____________________________________
List the name and title of the individual completing the form on behalf of the business.
Business Title * :
Name * :
Email * :
D.C. Law 22-250. Campaign Finance Reform Amendment Act of 2018. | D.C. Law Library (dccouncil.gov)
Since November 9, 2022, has the business entity or any of its Principals made a political contribution to any of the following: (i) the Mayor, (ii) any candidate for Mayor, (iii) any political committee affiliated with the Mayor or a candidate for Mayor, or (iv) any constituent-service program affiliated with the Mayor? [yes/no]
If yes, please provide the following information (for each contribution):
Date of contribution:
Amount of contribution:
Recipient of contribution:
Did the business entity hold any District contracts at the time the contribution was made or within one (1) year prior to the date the contribution was made? If yes, please provide award date and duration of the contract(s).
Since November 9, 2022, has the business entity or any of its Principals made a political contribution to any of the following: (i) the Attorney General, (ii) any candidate for Attorney General, or (iii) any political committee affiliated with the Attorney General or a candidate for Attorney General? [yes/no]
If yes, provide the following information (for each contribution):
Date of contribution:
Amount of contribution:
Recipient of contribution:
Department of General Services 3924 Minnesota Avenue, NE, Washington D.C. 20019 https://code.dccouncil.gov/us/dc/council/laws/22-250
Did the business entity hold any District contracts at the time the contribution was made or within one (1) year prior to the date the contribution was made? If yes, please provide the award date and duration of the contract(s).
Since November 9, 2022, has the business entity or any of its Principals made a political contribution to any of the following: (i) any Councilmember, (ii) any candidate for Councilmember, (iii) any political committee affiliated with a Councilmember or a candidate for Councilmember, or (iv) any constituent-service program affiliated with a Council member? [yes/no]
If yes, provide the following information (for each contribution):
Date of contribution:
Amount of contribution:
Recipient of contribution:
Did the business entity hold any District contracts at the time the contribution was made or within one (1) year prior to the date the contribution was made? If yes, please provide the award date and duration of the contract(s).
Prior to the date of this Certification, has the business entity been determined to be in violation of D.C. Official
Code § 1-1163.34a? [yes/no]
If yes, please explain including any resolution.
Is the business entity currently in violation of D.C. Official Code § 1-1163.34a? [yes/no]
If yes, please explain including any resolution.
Does the business entity certify that it will not be in violation of D.C. Official Code § 1-1163.34a? [yes/no]
“Principal” – any senior officer of a business entity, including an owner or co-owner, president, chief executive officer, chief operating officer, chief financial officer, treasurer, member, partner, or similar position which either sets or is authorized to set or otherwise influences the overall strategy of the business entity. A dean of an educational institution is not a “principal” within the meaning of this definition. A person whose only position at the business entity is as a board member is not a “principal” within the meaning of this definition.
Provide the names and titles of all the company principals (use additional sheets if required).
1.
2.
Who else will modify this certification for the business?
Modifier 1:
Modifier 2:
Check to certify that the information is accurate and complete. *
Check to acknowledge that the business must always keep these records updated*
Check to certify that the business entity currently is not and will not be in violation of the
Campaign Finance Reform Amendment Act of 2018 *
On behalf of the Contractor:
Name & Signature
Sworn to this before me this__ _day of _________________20___
Date
Notary public My Commission Expires
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