DFW1080ext.pdf
PDF 875 KB Posted
- Attached to
- RFQ-WLB-25-L-0018
- Solicitation number
- 0000037815
- Issued by
- California
About this file
This is a Darfur Contracting Act Certification form (DFW 1080) issued by the State of California Department of Fish and Wildlife for use in state and local contract opportunities. The form is required for bidders and proposers as part of the certification process for contract eligibility. Specifically, the form pertains to RFQ-WLB-25-L-0018, a California procurement for canvas photo prints for conference rooms. All bidders must complete the certification by selecting one of three options: certifying that the company has no business activities outside the United States in the previous three years, declaring status as a scrutinized company with written Department of General Services permission to bid, or certifying that despite having international business activities, the company is not a scrutinized entity as defined under Public Contract Code Section 10476.
The form requires bidders to provide their company name, Federal Employer Identification Number (FEIN), and the printed name and title of the authorized signatory. For options one and two, initials are sufficient; option three requires both initials and a formal certification signed under penalty of perjury by an authorized company official. The certification must be executed within a California county and state. Per Public Contract Code Section 10478, failure to include this completed form with either paragraph one or two initialed, or paragraph three fully executed, will result in disqualification of State Price Schedule applications. No pricing, set-asides, incumbents, or other contract terms are specified in this certification document.
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Other files
| File | Type | Posted |
|---|---|---|
| std204.pdf | ||
| CalRecycle_74_(Revised_01-23)_.pdf | ||
| Sellers-Permit_Example.png | PNG image | |
| WLB-25-L-0018_Canvas_Prints.docx | DOCX document | |
| DFW1082ext.pdf |
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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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