Purchaisng Affidavit.pdf
PDF 41 KB Posted
- Attached to
- PRESTRESSED CONCRETE BOX BEAMS
- Solicitation number
- CRFQ 0803 DOT1500000096 1
- Issued by
- Braxton County, West Virginia
About this file
This is a Purchasing Affidavit form issued by the West Virginia State Purchasing Division for RFQ No. DOT1500000096. The form serves as a mandatory compliance document under W. Va. Code 5A-3-10a that vendors must complete and notarize before contract awards can be issued by the state or its political subdivisions. The affidavit requires vendors to affirm under penalty of law that neither they nor any related parties owe debts exceeding one thousand dollars in aggregate or are in employer default status. The form includes definitions of key terms including "debt" (any assessment, premium, penalty, fine, tax, or judgment owed to the state or political subdivisions), "employer default" (outstanding balance to workers' compensation funds, policy default, or failure to maintain mandatory coverage), and "related party" (individuals or entities with blood, marriage, or ownership relationships representing five percent or more of contract benefit). Vendors must provide their name, authorized signature, date, state, and county of notarization.
An exception to the debt prohibition applies when vendors have contested taxes, workers' compensation premiums, permit fees, or environmental assessments that have not become final, or when vendors have entered into and remain compliant with payment plans or agreements. The affidavit must be sworn before a notary public with an affixed seal and current commission expiration date. False statements made under this affidavit constitute perjury under W. Va. Code 61-5-3. This document is a prerequisite requirement rather than a stand-alone procurement solicitation and does not contain pricing information, contract terms, scope of work details, or performance specifications.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
RFQ No. __________________
STATE OF WEST VIRGINIA
Purchasing Division
PURCHASING AFFIDAVIT
MANDATE: Under W. Va. Code §5A-3-10a, no contract or renewal of any contract may be awarded by the state or any of its political subdivisions to any vendor or prospective vendor when the vendor or prospective vendor or a related party to the vendor or prospective vendor is a debtor and: (1) the debt owed is an amount greater than one thousand dollars in the aggregate; or (2) the debtor is in employer default.
EXCEPTION: The prohibition listed above does not apply where a vendor has contested any tax administered pursuant to chapter eleven of the W. Va. Code, workers’ compensation premium, permit fee or environmental fee or assessment and the matter has not become final or where the vendor has entered into a payment plan or agreement and the vendor is not in default of any of the provisions of such plan or agreement.
DEFINITIONS:
“Debt” means any assessment, premium, penalty, fine, tax or other amount of money owed to the state or any of its political subdivisions because of a judgment, fine, permit violation, license assessment, defaulted workers’ compensation premium, penalty or other assessment presently delinquent or due and required to be paid to the state or any of its political subdivisions, including any interest or additional penalties accrued thereon.
“Employer default” means having an outstanding balance or liability to the old fund or to the uninsured employers' fund or being in policy default, as defined in W. Va. Code § 23-2c-2, failure to maintain mandatory workers' compensation coverage, or failure to fully meet its obligations as a workers' compensation self-insured employer. An employer is not in employer default if it has entered into a repayment agreement with the Insurance Commissioner and remains in compliance with the obligations under the repayment agreement.
“Related party” means a party, whether an individual, corporation, partnership, association, limited liability company or any other form or business association or other entity whatsoever, related to any vendor by blood, marriage, ownership or contract through which the party has a relationship of ownership or other interest with the vendor so that the party will actually or by effect receive or control a portion of the benefit, profit or other consideration from performance of a vendor contract with the party receiving an amount that meets or exceed five percent of the total contract amount.
AFFIRMATION: By signing this form, the vendor’s authorized signe r affirms and acknowledges under penalty of law for false swearing ( W. Va. Code §61-5-3) that neither vendor nor any related party owe a debt as defined above and that neither vendor nor any related party are in employer default as defined above, unless t he debt or employer default is permitted under the exception a bove.
WITNESS THE FOLLOWING SIGNATURE:
Vendor’s Name: ___________________________________________________________________________________
Authorized Signature: ______________________________________________ Date: ___________________________
State of _____________________________
County of ______________________, to-wit:
Taken, subscribed, and sworn to before me this ___ day of ____________________________, 20___.
My Commission expires ______________________________, 20___.
AFFIX SEAL HERE NOTARY PUBLIC ____________________________________
Purchasing Affidavit (Revised 07/01/2012)
| RFQ No: DOT1500000096 |
| Vendors Name: |
| Date: |
| State of: |
| County of: |
| day of: |
| My Commission expires: |
| Text50: |
| Text51: |
| Text52: |
File details come from the government source that posted it. Updated .