Federal_Debarment_Certification_Form_Final_(9-12-23).pdf
PDF 110 KB Posted
- Solicitation number
- 26-024EN-IFB
- Issued by
- Hillsborough County, Florida
About this file
This is a Federal Debarment Certification Form required by the Department of Labor for lower tier covered transactions under Executive Orders 12549 and 12689, implementing regulations found in 2 C.F.R. Part 180. The certification applies to the North Woodrow Wilson Street Sidewalk Improvements CDBG project in Florida, which involves sidewalk addition on the east side of N. Woodrow Wilson Street from W. Lowry Avenue to the CSX railroad. The project scope includes flexible paving, grading, drainage, concrete sidewalks and driveways, stripping, signage, tree removal, sodding, and replacement of an existing potable watermain and appurtenances, with coordination of underground private utility relocations.
The form requires that prospective recipients of federal assistance funds certify compliance with 2 C.F.R. Part 180 and attest that neither they, their principals, nor their subcontractors are currently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from federal participation. Signatories must acknowledge that false, fictitious, or fraudulent information may subject them to criminal, civil, or administrative penalties under U.S. Code Title 18, Sections 3729-3730 and 3801-3812. The certification requires notarization in the State of Florida and must be signed by an authorized representative before submission. Any changes to the certification status after submission must be reported immediately in writing to the recipient agency.
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Text version
FEDERAL DEBARMENT CERTIFICATION 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 (1986) and Executive Order 12689, Debarment and Suspension (1989) at 2 C.F.R. Part 180.
(BEFORE COMPLETING CERTIFICATION, READ THE ENTIRE FORM)
1) The prospective recipient of Federal assistance funds certifies, by Response, that it is in compliance with the requirements of 2 C.F.R.
Part 180 and that neither it, its principals, nor its subcontractors are 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 recipient of Federal assistance funds is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this Response.
3) By signing and submitting this Response, the prospective recipient of Federal assistance funds is providing the certification as set out below.
4) The certification in this class 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 recipient of Federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the Department of Labor (DOL) may pursue available remedies, including suspension and/or debarment.
5) The prospective recipient of Federal assistance funds shall provide immediate written notice to the person to which this Response is submitted if at any time the prospective recipient of Federal assistance funds learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
6) The prospective recipient of Federal assistance funds agrees by submitting this Response 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 DOL.
7) The prospective recipient of Federal assistance funds further agrees by submitting this Response 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.
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Attestation/Signature Page to Follow
DEBARMENT CERTIFICATION ATTESTATION
By signing this report, I certify to the best of my knowledge and belief that the foregoing is true, complete, and accurate. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Sections 3729-3730 and 3801-3812).
Company Name
Name and Title of Authorized Representative
Signature
STATE OF FLORIDA
COUNTY OF _______________________________
The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this _____ day of _______________________, 20_____ by _________________________ of ________________________________, (Authorized Signer) (Company Name) a Florida for profit ☐ or limited liability company ☐, on behalf of the corporation ☐/limited liability company ☐. He/she is personally known to me or has produced ________________
(Type of ID) as identification.
[Notary Seal] Notary Public
Name typed, printed or stamped My Commission Expires: ___________
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