IRE_NONCOLLUSIONAFFIDAVIT3.pdf
PDF 34 KB Posted
- Attached to
- 4618-20261013152026 Hattiesburg
- Solicitation number
- 3170036835
- Issued by
- Greene County, Mississippi
About this file
This is a Non-Collusion Affidavit for Hattiesburg Clinic RFP No. HC-RTG-2026-IRE for an EHR Isolated Recovery Environment (IRE) Service. The affidavit is a required submission attachment that bidders must complete and have notarized as part of their proposal response. The document establishes the legal framework for competitive bidding by requiring the affiant, who must be an authorized representative of the bidding company, to certify that the proposal is genuine and that no collusive or anti-competitive practices have occurred in its preparation or submission.
The affidavit requires bidders to confirm that proposal prices were developed independently without consultation or communication with competitors, that no attempts have been made to restrict competition, and that no officers or agents of Hattiesburg Clinic have financial interests in the bidder or have received gratuities related to the solicitation. Additionally, bidders must certify that they and their principals are not debarred, suspended, or otherwise ineligible to participate in federally funded transactions, as determined by 2 CFR Part 180. The affidavit must be signed by the authorized company representative and notarized, with all required fields completed including company legal name, address, UEI from SAM.gov, and date of execution.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| IRE_PRICING_FORM2.pdf | ||
| 4618-20261013152026 HATTIESBURG CLINIC.pdf |
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Text version
Hattiesburg Clinic RFP No. [HC-RTG-2026-IRE] — Attachment A
Attachment A Non-Collusion Affidavit
Hattiesburg Clinic RFP No. [HC-RTG-2026-IRE] — EHR Isolated Recovery Environment (IRE) Service
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-IRE] — 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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