IranFreeProcurementCertificationForm.pdf
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- Attached to
- 12 8413 Actuarial Services SWIF
- Solicitation number
- 6100066762
- Issued by
- Dauphin County, Harveys Lake Borough, Pennsylvania
About this file
This is an Iran Free Procurement Certification Form established under Pennsylvania's Procurement Code Sections 3501-3506, applicable to the Commonwealth of Pennsylvania and all entities contracting with state agencies. The form establishes eligibility requirements for vendors and financial institutions seeking contracts valued at $1,000,000 or more with Commonwealth entities. Vendors must either certify that they are not engaged in investment activities in Iran, as determined by the Pennsylvania Department of General Services (DGS), or demonstrate that they have obtained a written exemption from DGS on a case-by-case basis. The form provides two certification options: Option #1 allows vendors to certify their non-involvement in Iran investment activities and eligibility to contract under the Procurement Code; Option #2 permits vendors who have received a DGS exemption to proceed with contracting. Both options require completion by an authorized representative with signature, printed name, title, and date of execution.
Pennsylvania law imposes substantial penalties for false certifications, including civil penalties equal to the greater of $250,000 or twice the contract amount, contract termination, and three-year ineligibility to bid on Commonwealth contracts. This certification requirement applies to the Actuarial Services contract with the State Workers' Insurance Fund (SWIF) under the Department of Labor and Industry, which seeks qualified independent contractors to provide actuarial analysis, reserve evaluation, actuarial opinions, and related consulting services to support SWIF's financial reporting and workers' compensation insurance operations. All contractors must comply with applicable Actuarial Standards of Practice, statutory accounting principles, Pennsylvania workers' compensation laws, and federal and state regulatory requirements, including privacy and information security standards.
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Text version
BOP-1701
Published: 1/26/2017
IRAN FREE PROCUREMENT CERTIFICATION FORM
(Pennsylvania’s Procurement Code Sections 3501-3506, 62 Pa.C.S. §§ 3501-3506)
To be eligible for an award of a contract with a Commonwealth entity for goods or services worth at least $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 Pennsylvania Department of General Services (“DGS”) pursuant to Section 3503 of the Procurement Code and is eligible to contract with the Commonwealth under Sections 3501-3506 of the Procurement Code; or b) demonstrate it has received an exception from the certification requirement for that solicitation or contract pursuant to Section 3503(e).
To comply with this requirement, please insert your vendor or financial institution name and complete one of the options below. Please note: Pennsylvania 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. (Section 3503 of the Procurement Code.)
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 eligible to contract with the Commonwealth of Pennsylvania Sections 3501-3506 of the Procurement Code.
Vendor Name/Financial Institution (Printed)
By (Authorized Signature)
Printed Name and Title of Person Signing Date Executed
OPTION #2 – EXEMPTION
Pursuant to Procurement Code Section 3503(e), DGS may permit a vendor/financial institution engaged in investment activities in Iran, on a case-by-case basis, to enter into a contract for goods and services.
If you have obtained a written exemption from the certification requirement, please fill out the information below, and attach the written documentation demonstrating the exemption approval.
Vendor Name/Financial Institution (Printed)
By (Authorized Signature)
Printed Name and Title of Person Signing Date Executed
| IRAN FREE PROCUREMENT CERTIFICATION FORM |
| (Pennsylvania’s Procurement Code Sections 3501-3506, 62 Pa.C.S. §§ 3501-3506) |
| OPTION #1 - CERTIFICATION |
| OPTION #2 – EXEMPTION |
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