Darfur_Certification_DFW1080ext_[Fillable].pdf
PDF 875 KB Posted
- Solicitation number
- 0000032859
- Issued by
- Contra Costa County, California
About this file
This document is a Darfur Contracting Act Certification form required by the California Department of Fish and Wildlife for state and local contract opportunities. The certification form requires bidders/proposers to certify whether they currently have or have had within the previous three years any business activities or operations outside of the United States. Bidders must initial one of three paragraphs to indicate their status. If a bidder has had out-of-country operations, they must certify that they are not a "scrutinized" company as defined in the Public Contract Code. This certification must be completed and submitted with the bid or proposal in order to be considered eligible.
The document outlines the penalty of perjury associated with the certification and requires an authorized signature. It notes that State Price Schedule (SPS) applications will be disqualified without this completed form.
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Text version
State of California - Department of Fish and Wildlife
DARFUR CONTRACTING ACT CERTIFICATION
DFW 1080 (NEW 02/14/19)
Pursuant to California Code, Public Contract Code (PCC) – PCC § 10478, if a bidder or proposer currently or within the previous three years has had business activities or other operations outside of the United States, it must certify that it is not a “scrutinized” company as defined in PCC § 10476.
Therefore, to be eligible to submit a bid or proposal, please insert your company name and Federal ID Number (FEIN) and complete only one of the following three paragraphs (via initials for paragraph 1 or paragraph 2, or via initials and certification for paragraph 3)
Company/Vendor Name (Printed) FEIN
Printed Name and Title of Person Initialing (option 1 or 2) Date
1. _______ Initials
2. ________ Initials
3.
Initials
We do not currently have, or we have not had within the previous three years, business activities or other operations outside of the United States.
OR
We are a scrutinized company as defined in PCC § 10476, but we have received written permission from the Department of General Services (DGS) to submit a bid or proposal pursuant to PCC § 10477(B). A copy of the written permission from DGS is included with our bid or proposal.
OR
We currently have, or we have had within the previous three years, business activities or other operations outside of the United States, but we certify below that we are not a scrutinized company as defined in PCC § 10476.
CERTIFICATION For 3 I, the official named below, CERTIFY UNDER PENALTY OF PERJURY that I am duly authorized to legally bind the prospective proposer/bidder to the clause listed above in paragraph 3. This certification is made under the laws of the State of California.
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed Executed in the County and State of
NOTE: State Price Schedule (SPS) Applications will be disqualified unless your application includes this form with either paragraph 1 or paragraph 2 initialed or paragraph 3 initialed and certified.
| OR |
| OR |
| CompanyVendor Name Printed: |
| FEIN: |
| Printed Name and Title of Person Initialing option 1 or 2: |
| Date: |
| Initials: |
| Initials_2: |
| Initials_3: |
| Printed Name and Title of Person Signing: |
| Date Executed: |
| Executed in the County and State of: |
| SAVE: |
| PRINT: |
| CLEAR: |
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