Debarment form.doc
DOC document 45 KB Posted
- Solicitation number
- ILG0021
- Issued by
- Wisconsin
About this file
This is a Debarment Certification Form required by the Department of Workforce Development, State of Wisconsin, for lower tier covered transactions under Executive Order 12549. The form serves as a mandatory certification that prospective participants in state and federal procurement transactions affirm that neither they nor their principals are currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation by any Federal department or agency. The certification must be completed and signed by an authorized representative of the company or organization submitting a proposal or bid. If a prospective participant is unable to certify to the statements contained in the form, they are required to attach a written explanation to their proposal or bid submission.
The form establishes that submission of the certification constitutes a material representation of fact upon which the government relies when entering into the transaction. Bidders must provide immediate written notice if they later discover that their certification was erroneous at the time of submission or has become erroneous due to changed circumstances. The certification further obligates participants not to knowingly enter into lower tier covered transactions with debarred, suspended, ineligible, or voluntarily excluded persons unless authorized by the contracting agency. Participants agree to include identical certification language in all lower tier covered transactions and solicitations. Knowingly violating these provisions subjects participants to available remedies including suspension and debarment. The form applies to any procurement contract for goods or services with the Department of Workforce Development expected to equal or exceed the Federal procurement small purchase threshold.
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Other files
| File | Type | Posted |
|---|---|---|
| ILG0021 - CSNA RFP_Final.pdf | ||
| ILG0021 - Addendum 01 - QA DRAFT 9.5.17 FINAL.pdf |
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Text version
Debarment Form
CERTIFICATION REGARDING
DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
LOWER TIER COVERED TRANSACTIONS
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 29 CFR Part 98, Section 98.510, Participants' responsibilities. The regulations were published as Part 98 of the July 1, 1993 Code of Federal Regulations (pages 537-555).
(Before Completing Certification, Read Attached Instructions
Which Are an Integral Part of the Certification)
1.
The prospective lower tier participant certifies, by submission of this proposal, to the Department of Workforce Development, State of Wisconsin, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.
2.
Where the prospective lower tier participant is unable to certify to any of the statements in this certification, to the Department of Workforce Development, State of Wisconsin, such prospective participant shall attach an explanation to this proposal/bid.
Name and Title of Authorized Representative
Signature
Date
Company/Organization Name
DWD-xxxx-xx Contract/Bid/Bulletin Number
Definitions:
Lower tier transaction: Any procurement contract for goods or services between a participant and the Department of Workforce Development, State of Wisconsin, regardless of type expected to equal or exceed the Federal procurement small purchase threshold under a primary covered transactions.
Primary covered transaction: Any nonprocurement transaction between the Department of Workforce Development, State of Wisconsin and a Federal agency including: grants, cooperative agreements, scholarships, fellowships, contracts of assistance, loans, loan guarantees, subsidies, insurance, payments for specified use, donation agreements and any other nonprocurement transactions.
DWD USE ONLY
Contract No.
Bid No.
Contract Period
RFP No.
BUL. No.
Comm. Code:
rev. 2/95
INSTRUCTIONS FOR CERTIFICATION
1.
By signing and submitting this proposal, the prospective lower tier participant providing the certification as set out below.
2.
The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
3.
The prospective lower tier participant shall provide immediate written notice to the person to which this proposal is submitted if at any time the lower tier participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
4.
The term "covered transaction,” “debarred,” “suspended”, “ineligible,” “lower tier covered transaction,” ”participant,” “person,” “primary covered transaction,” “principal, proposal," and "voluntarily excluded," as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those regulations.
5.
The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the department or agency with which this transaction originated.
6.
The prospective lower tier participant further agrees by submitting this proposal that it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
7.
A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not debarred, suspended, declared ineligible, or voluntarily excluded from participation in the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. Each participant may but is not required to check the Nonprocurement List.
8.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
9.
Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
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