DOT172612_PURCHASING AFF.pdf
PDF 30 KB Posted
- Attached to
- HP 12x53 STEEL PILING
- Solicitation number
- CRFQ 0803 DOT1600000061 1
- Issued by
- Mercer County, West Virginia
About this file
This is a Purchasing Affidavit form issued by the State of West Virginia Purchasing Division that establishes eligibility requirements for vendors seeking state contracts. Under W. Va. Code 5A-3-10a, the state prohibits contract awards to vendors or their related parties that owe debts exceeding $1,000 in aggregate or are in employer default status. The affidavit must be completed and notarized by an authorized vendor representative, with the signature taken before a notary public who affixes their seal and commission expiration date to the document.
The form includes specific exceptions to the debt prohibition for vendors that have contested taxes, workers' compensation premiums, permit fees, or environmental assessments where the matter remains pending, or for vendors that have entered into and are compliant with payment plans or repayment agreements. "Debt" is defined broadly to include assessments, premiums, penalties, fines, taxes, and amounts owed due to judgments, permit violations, license assessments, or defaulted workers' compensation premiums with accrued interest. "Related party" refers to individuals or entities connected to the vendor through blood, marriage, ownership, or contract that would receive or control benefits equaling five percent or more of the total contract amount. By executing the affidavit under penalty of law for false swearing, the vendor's authorized signer affirms that neither the vendor nor any related party owes qualifying debt or is in employer default status as defined in the regulation.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| DOT172612_SPECIFICATIONS.pdf | ||
| DOT172612_VENDOR PREFERENCE.pdf | ||
| Final_CRFQ_0803_DOT1600000061_1_CRFQ_FORM.PDF | ||
| DOT172612_TERMS AND COND.pdf |
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Text version
STATE OF WEST VIRGINIA
Purchasing Division
MANDATE: Under W. Va. Code §5A-3-10a, 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 ____________________________________
Purchasing Affidavit (Revised 08/01/2015)
File details come from the government source that posted it. Updated .