B08 - Attachment 3 Tax-and-Felony-Representation-Form.pdf
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- Opportunity number
- W911SR-24-S-0001
About this file
This document is a Representations under DoD Assistance Agreements: Appropriations Provisions on Tax Delinquency and Felony Convictions form. It requires applicants that are corporations to represent whether they have any unpaid federal tax liabilities or have been convicted of a criminal violation under federal law within the preceding 24 months. If the applicant responds affirmatively to either representation, they are ineligible for award unless the suspension and debarment official determines further action is not required to protect the government's interests.
The federal grant opportunity this form is associated with is the Minority Serving Institutions (MSIs) and Historically Black Colleges and Universities (HBCUs) Science, Technology, Engineering and Mathematics (STEM) Consortium. This $XX million cooperative agreement opportunity is funded under the Basic, Applied, and Advanced Research in Science and Engineering program (CFDA 12.630) and is being administered by the Department of the Army Materiel Command Army Contracting Command Aberdeen Proving Ground.
B08 - Attachment 3 Tax-and-Felony-Representation-Form
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Text version
Representations under DoD Assistance Agreements: Appropriations Provisions on Tax Delinquency and Felony Convictions
The applicant is ( ) is not ( ) a “Corporation” meaning any entity, including any institution of higher education, other nonprofit organization, or for-profit entity that has filed articles of incorporation.
If the applicant is a “Corporation” please complete the following representations:
(1) The applicant represents that it is ( ) is not ( ) a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.
(2) The applicant represents that it is ( ) is not ( ) is not a corporation that was convicted of a criminal violation under any Federal law within the preceding 24 months.
NOTE: If an applicant responds in the affirmative to either of the above representations, the applicant is ineligible to receive an award unless the agency suspension and debarment official (SDO) has considered suspension or debarment and determined that further action is not required to protect the Government’s interests. The applicant therefore should provide information about its tax liability or conviction to the agency’s SDO as soon as it can do so, to facilitate completion of the required considerations before award decisions are made.
Sign:___________________________________
Date:____________________________________
Print Name and Position:______________________________________________
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