Iran_Contracting_Act_Verification.pdf
PDF 54 KB Posted
- Attached to
- 25NC0665 Broadband Equity, Access and Deployment (BEAD) Program Administration and Oversight
- Solicitation number
- 0000039982
- Issued by
- San Francisco County, San Francisco City, California
About this file
This is an Iran Contracting Act Verification Form required by the State of California for vendors bidding on state contracts valued at $1,000,000 or more. The form enforces compliance with California Public Contract Code sections 2202-2208 and is administered by the California Department of General Services (DGS). Prior to bidding, proposal submission, or contract execution, vendors must either certify that they are not listed on the DGS's current Iran investment activities list or demonstrate an exemption has been granted for the specific solicitation. The certification requirement applies to all vendors and financial institutions seeking state contracts exceeding the $1,000,000 threshold, with no specific response dates, due dates, or contract terms detailed in the form itself.
The form provides two compliance options for vendors. Option 1 requires vendors to certify they are not on the DGS Iran Contracting Act List and are not financial institutions extending $20,000,000 or more in credit to persons using such credit for energy sector services in Iran. Option 2 permits vendors already engaged in Iran investment activities to submit documentation of case-by-case exemption approval obtained from the public entity. California law establishes significant penalties for false certifications, including civil penalties of $250,000 or twice the contract amount, whichever is greater, contract termination, and three-year ineligibility to bid on future contracts. The DGS maintains the current prohibited entities list online for vendor reference and verification purposes.
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Text version
IRAN CONTRACTING ACT VERIFICATION FORM
(Public Contract Code sections 2202-2208)
Prior to bidding on, submitting a proposal or executing a contract or renewal for a State of California contract for goods or services of $1,000,000 or more, a vendor must either: a) certify it is not on the current list of persons engaged in investment activities in Iran created by the California Department of General Services (“DGS”) pursuant to Public Contract Code section 2203(b) and is not a financial institution extending twenty million dollars ($20,000,000) or more in credit to another person, for 45 days or more, if that other person will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by DGS; or b) demonstrate it has been exempted from the certification requirement for that solicitation or contract pursuant to Public Contract Code section 2203(c) or (d). The DGS list of entities prohibited from contracting with public entities in California per the Iranian Contracting Act, 2010, can be found at:
Department of General Services Procurement Division Iran Contracting Act List
To comply with this requirement, please insert your vendor or financial institution name and Federal ID Number (if available) and complete one of the options below.
Please note: California law establishes penalties for providing false certifications, including civil penalties equal to the greater of $250,000 or twice the amount of the contract for which the false certification was made; contract termination; and three-year ineligibility to bid on contracts. (Public Contract Code section 2205.)
OPTION #1 - CERTIFICATION
I, the official named below, certify I am duly authorized to execute this certification on behalf of the vendor/financial institution identified below, and the vendor/financial institution identified below is not on the current list of persons engaged in investment activities in Iran created by DGS and is not a financial institution extending twenty million dollars ($20,000,000) or more in credit to another person/vendor, for 45 days or more, if that other person/vendor will use the credit to provide goods or services in the energy sector in Iran and is identified on the current list of persons engaged in investment activities in Iran created by
DGS.
https://www.dgs.ca.gov/-/media/Divisions/PD/PTCS/OPPL/Iran-Contracting-Act-List.pdf?la=en&hash=71776438AADF114D952082668B1D6A0AEED31C2B http://www.documents.dgs.ca.gov/PD/poliproc/Iran%20Contracting%20Act%20List.pdf
Vendor Name/Financial Institution (Printed) Federal ID Number (or n/a)
By (Authorized Signature)
Printed Name and Title of Person Signing
Date Executed Executed in
OPTION #2 – EXEMPTION
Pursuant to Public Contract Code sections 2203(c) and (d), a public entity may permit a vendor/financial institution engaged in investment activities in Iran, on a case-by-case basis, to be eligible for, or to bid on, submit a proposal for, or enters into or renews, a contract for goods and services.
If you have obtained an exemption from the certification requirement under the Iran Contracting Act, please fill out the information below, and attach documentation demonstrating the exemption approval.
Vendor Name/Financial Institution (Printed) Federal ID Number (or n/a)
By (Authorized Signature)
Printed Name and Title of Person Signing Date Executed
| OPTION #1 - CERTIFICATION |
| OPTION #2 – EXEMPTION |
| Vendor NameFinancial Institution Printed: |
| Federal ID Number or na: |
| By Authorized Signature: |
| Printed Name and Title of Person Signing: |
| Date Executed: |
| Executed in: |
| Vendor NameFinancial Institution Printed_2: |
| Federal ID Number or na_2: |
| By Authorized Signature_2: |
| Printed Name and Title of Person Signing_2: |
| Date Executed_2: |
| ADA Instructions: |
| Date3_af_date: |
| Date4_af_date: |
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