Darfur_Certification_DFW1080ext_[Fillable].pdf
PDF 875 KB Posted
- Solicitation number
- 0000033621
- Issued by
- Marin County, California
About this file
This is a Darfur Contracting Act Certification form (DFW 1080) required by the California Department of Fish and Wildlife for bidders and proposers. The form requires companies to certify their business activities in relation to the Darfur region, as mandated by California Public Contract Code § 10478. Companies must declare whether they have had business operations outside the United States within the previous three years and certify they are not a "scrutinized company" as defined in PCC § 10476.
The certification provides three options for companies: 1) declare no business activities outside the US in the past three years, 2) acknowledge status as a scrutinized company but provide written DGS permission to bid, or 3) declare international business activities while certifying non-scrutinized status. The form must be included with State Price Schedule (SPS) Applications, and applications will be disqualified if the form is not properly completed with either paragraphs 1 or 2 initialed, or paragraph 3 initialed and certified under penalty of perjury.
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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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