HC_TERTIARY_WAN_COLLUSION_AFFIDAVIT3.pdf
PDF 34 KB Posted
- Attached to
- 4618-20261013152621 Hattiesburg
- Solicitation number
- 3170036836
- Issued by
- Hancock County, Mississippi
About this file
This document is a Non-Collusion Affidavit form for Hattiesburg Clinic's Request for Proposal No. HC-RTG-2026-WAN for Tertiary Cellular WAN Service for Rural Clinic Sites. The affidavit is a required attachment (Attachment A) that bidders must complete and submit with their proposals. The form requires the affiant to provide their name, title, and company information, along with a notarized signature attesting to the authenticity and independence of the bid submission. No specific service delivery dates, response deadlines, site visits, bidder conferences, or contract award dates are referenced in this document.
The affidavit requires bidders to certify under oath that their proposal is genuine and has not been developed through collusion with competitors, that pricing has been determined independently, that no gratuities or financial incentives have been offered to Hattiesburg Clinic personnel or evaluation committee members, and that neither the bidder nor its principals are debarred or suspended from federal transactions. The document also requires certification of compliance with 2 CFR Part 180 regarding federal debarment status. This is a standard integrity and compliance document with no pricing terms, set-asides, incumbent information, or funding sources specified within its contents.
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Other files
| File | Type | Posted |
|---|---|---|
| HC_CELLWAN_ATTACHMENT_B_PRICING_FORM2.pdf | ||
| 4618-20261013152621 HATTIESBURG CLINIC.pdf |
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Text version
Hattiesburg Clinic RFP No. [HC-RTG-2026-WAN] — Attachment A
Attachment A Non-Collusion Affidavit
Hattiesburg Clinic RFP No. [HC-RTG-2026-WAN] — Tertiary Cellular WAN Service for Rural Clinic Sites
STATE OF ______________________________
COUNTY OF ____________________________
I, _________________________________________ (name of affiant), being first duly sworn, depose and state that:
1. I am the _______________________________ (title) of _________________________________________________ (legal name of company), the bidder that has submitted the attached proposal, and I am fully authorized to make this affidavit on behalf of the bidder.
2. I am fully informed with respect to the preparation and contents of the attached proposal and of all pertinent circumstances respecting it.
3. The proposal is genuine and is not a collusive or sham proposal.
4. Neither the bidder nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, has in any way colluded, conspired, connived or agreed, directly or indirectly, with any other bidder, firm or person to submit a collusive or sham proposal in connection with this solicitation, or to refrain from submitting a proposal.
5. The prices in the proposal have been arrived at independently, without consultation, communication or agreement with any other bidder or competitor for the purpose of restricting competition, and have not been knowingly disclosed to any other bidder or competitor before the proposal opening.
6. No attempt has been made or will be made by the bidder to induce any other person or firm to submit or not to submit a proposal for the purpose of restricting competition.
7. No officer, employee, or agent of Hattiesburg Clinic, P.A., and no member of the Clinic’s evaluation committee, has any financial interest in the bidder or in this proposal, and the bidder has not offered or given any gratuity, favor, or anything of monetary value to any such person in connection with this solicitation.
8. The bidder, and its principals, are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in transactions funded by the federal government (2 CFR Part 180).
9. The statements in this affidavit are true and correct, and I understand that any false statement may result in rejection of the proposal, termination of any resulting contract, and other remedies available at law.
Hattiesburg Clinic RFP No. [HC-RTG-2026-WAN] — Attachment A
BIDDER / AFFIANT
Field Entry
Signature of affiant
Printed name
Title
Company (legal name)
Address
UEI (SAM.gov)
Date
NOTARY
Subscribed and sworn to before me this ______ day of ____________________, 20____.
Notary Public signature
Printed name
My commission expires: ______________________
(SEAL)
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