B08_Attachment 6- Anti mafia_20211006.pdf

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Office Furnishings and Incidental Services
Solicitation number
W912PF22Q0003
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This solicitation requests quotes for office furnishings and incidental services to outfit a newly renovated building for an Army Department of Public Works. Required items include desks, chairs, workstations and other furnishings as detailed in Attachment 1. Italian vendors must complete and submit Attachment 6 on anti-mafia self-certification with their quotes. The Army Contracting Command and Materiel Command are conducting this simplified acquisition under FAR Part 13.5 for commercial items. Quotes are due by the date specified in the full RFQ posted on SAM.gov. The solicitation is also subject to availability of funds clause 52.232-18.

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ATTACHMENT 4

Autocertificazione della comunicazione antimafia.

Dichiarazione sostitutiva di certificazione (D.P.R. n. 445 del 28.12.2000)

Il/la sottoscritto/a (nome e cognome) C.F._ nato/a Prov. il residente a Prov. in via/piazza

n. , in qualità di (carica ricoperta) dell’impresa

(indicare la denominazione) C.F.

avente la sede in n.

Prov. di via consapevole delle sanzioni penali in caso di dichiarazioni false e della conseguente decadenza dai benefici eventualmente conseguiti (ai sensi degli artt. 75 e 76 D.P.R. 445/2000) sotto la propria responsabilità

DICHIARA

□ che nei propri confronti non sussistono le cause di divieto, di decadenza o di sospensione di cui all’art. 67 del D.lgs. n. 159 del 06/09/2011.

Il/la sottoscritto/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di dati personally) che i dati personali raccolti saranno trattati, anche con strumenti informatici, esclusivamente nell’ambito del procedimento per il quale la presente dichiarazione viene resa.

Data Firma leggibile del dichiarante

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