Purchasing Affidavit 080115.pdf
PDF 40 KB Posted
- Attached to
- Wall Switch Sensors
- Solicitation number
- ARFQ 0211 GSD1600000094 1
- Issued by
- Lincoln County, West Virginia
About this file
This is a Purchasing Affidavit form issued by the West Virginia Purchasing Division under W. Va. Code 5A-3-10a, applicable to all state contracts and contracts awarded by West Virginia political subdivisions. The form serves as a mandatory certification requirement for vendors seeking contract awards. Vendors must affirm under penalty of perjury that neither they nor any related parties owe debts exceeding one thousand dollars in aggregate or are in employer default status. The affidavit does not apply to vendors who have contested applicable taxes, workers' compensation premiums, permit fees, or environmental assessments where the matter remains pending, or to vendors operating under compliant payment plans or repayment agreements with the Insurance Commissioner.
The document defines key terms including "debt" as any assessment, penalty, fine, tax, or other monies owed to the state or its subdivisions that are delinquent or due, and "employer default" as outstanding balances to workers' compensation funds, policy defaults, failure to maintain mandatory coverage, or non-compliance with self-insurance obligations. "Related party" is defined as any individual, corporation, partnership, or other entity connected to the vendor by blood, marriage, ownership, or contract through which the party receives or controls at least five percent of the total contract benefit or profit. The affidavit requires signature by an authorized vendor representative and notarization, with the notary affixing an official seal and commission expiration date.
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Other files
| File | Type | Posted |
|---|---|---|
| Final_ARFQ_0211_GSD1600000094_1_ARFQ_FORM.PDF | ||
| Agency Instructions to Vendors Submitting Bids 102715.pdf | ||
| T and C.pdf |
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Text version
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 signer 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 the debt or employer default is permitted under the exception above.
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 08/01/2015)
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