DEP1700000055 DEP PROCUREMENT AFFIDAVIT.pdf
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- Solicitation number
- ARFQ 0313 DEP1700000055 3
- Issued by
- Raleigh County, West Virginia
About this file
This is a Procurement Affidavit form issued by the West Virginia Department of Environmental Protection that establishes vendor eligibility requirements for state and local contract awards. The affidavit prohibits contract awards to any vendor or prospective vendor, or related parties to such vendors, who owe debts exceeding one thousand dollars in aggregate or who are in employer default status. The form requires vendor authorization signers to affirm under penalty of perjury that neither the vendor nor any related party owes prohibited debts or is in employer default, unless exceptions apply. Related parties are defined as individuals, corporations, partnerships, associations, limited liability companies, or other entities connected to the vendor through blood, marriage, ownership, or contract relationships that would result in the related party receiving or controlling five percent or more of the total contract amount.
The affidavit provides limited exceptions to the debt prohibition for vendors who have contested taxes, workers' compensation premiums, permit fees, or environmental fees or assessments while matters remain pending, or for vendors who have entered into and are complying with payment plans or agreements. Employer default status includes outstanding balances to workers' compensation funds, policy defaults, failure to maintain mandatory coverage, or failure to meet self-insured employer obligations, though employers may remedy this status by entering into and complying with repayment agreements with the Insurance Commissioner. The form requires notarization and must be executed by the vendor's authorized representative with the vendor's name, authorized signature, date, and notary public seal affixed.
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WV Department of Environmental Protection
PROCUREMENT AFFIDAVIT
No contract or renewal of any contract may be awarded by the state or any of its political subdivisions to any vendor or prospective vendor when the vendor or prospective vendor or a related party to the vendor or prospective vendor is a debtor and: (1) the debt owed is an amount greater than one thousand dollars in the aggregate; or (2) the debtor is in employer default.
EXCEPTION: The prohibition listed above does not apply where a vendor has contested any tax administered pursuant to chapter eleven of the W. Va. Code, workers’ compensation premium, permit fee or environmental fee or assessment and the matter has not become final or where the vendor has entered into a payment plan or agreement and the vendor is not in default of any of the provisions of such plan or agreement.
DEFINITIONS:
“Debt” means any assessment, premium, penalty, fine, tax or other amount of money owed to the state or any of its political subdivisions because of a judgment, fine, permit violation, license assessment, defaulted workers’ compensation premium, penalty or other assessment presently delinquent or due and required to be paid to the state or any of its political subdivisions, including any interest or additional penalties accrued thereon.
“Employer default” means having an outstanding balance or liability to the old fund or to the uninsured employers' fund or being in policy default, as defined in W. Va. Code § 23-2c-2, failure to maintain mandatory workers' compensation coverage, or failure to fully meet its obligations as a workers' compensation self-insured employer. An employer is not in employer default if it has entered into a repayment agreement with the Insurance Commissioner and remains in compliance with the obligations under the repayment agreement.
“Related party” means a party, whether an individual, corporation, partnership, association, limited liability company or any other form or business association or other entity whatsoever, related to any vendor by blood, marriage, ownership or contract through which the party has a relationship of ownership or other interest with the vendor so that the party will actually or by effect receive or control a portion of the benefit, profit or other consideration from performance of a vendor contract with the party receiving an amount that meets or exceed five percent of the total contract amount.
AFFIRMATION: By signing this form, the vendor’s authorized signer affirms and acknowledges under penalty of law for false swearing (W. Va. Code §61-5-3) that neither vendor nor any related party owe a debt as defined above and that neither vendor nor any related party are in employer default as defined above, unless the debt or employer default is permitted under the exception above.
WITNESS THE FOLLOWING SIGNATURE:
Vendor’s Name: _ _ _
Authorized Signature: _ Date:
State of _
County of , to-wit:
Taken, subscribed, and sworn to before me this _ day of _ _, 20_ .
My Commission expires _ , 20_ .
AFFIX SEAL HERE NOTARY PUBLIC _ _
Procurement Affidavit (Revised 06/06/2016)
| WV Department of Environmental Protection |
| DEFINITIONS: |
| AFFIRMATION: By signing this form, the vendor’s authorized signer affirms and acknowledges under penalty of law for false swearing (W. Va. Code §61-5-3) that neither vendor nor any related party owe a debt as defined above and that neither vendor nor ... |
| AFFIX SEAL HERE NOTARY PUBLIC _ _ |
| Vendors Name: |
| Date: |
| State of: |
| County of: |
| day: |
| month: |
| My Commission expires Date: |
| Notary Signature: |
| year: |
| year exp: |
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