Purchasing Affidavit.pdf
PDF 40 KB Posted
- Attached to
- Cedar Creek - Concrete
- Solicitation number
- ARFQ 0310 DNR1600000085 1
- Issued by
- Grant County, West Virginia
About this file
This is a Purchasing Affidavit form issued by the State of West Virginia Purchasing Division that establishes eligibility requirements for vendors seeking state and local contracts. The affidavit mandates that no vendor or prospective vendor with outstanding debts exceeding one thousand dollars in aggregate, or those in employer default status, may be awarded contracts by the state or its political subdivisions. The form requires vendors' authorized signers to affirm under penalty of law that neither they nor any related parties owe prohibited debts or are in employer default, unless the debt is subject to specific exceptions such as contested taxes, workers' compensation premiums, permit fees, or environmental assessments that remain unresolved, or debts covered by active payment plans in which the vendor maintains compliance.
The affidavit defines key terms including "debt" as any assessment, penalty, fine, tax, or other delinquent amount owed to the state or its subdivisions, and "employer default" as outstanding workers' compensation liabilities, policy defaults, or failure to maintain mandatory coverage. The definition of "related party" encompasses individuals, corporations, partnerships, and other entities with ownership or contractual relationships to the vendor that would result in receiving or controlling five percent or more of the total contract benefit. The document requires notarization and must be signed and dated by the vendor's authorized representative along with the notary public's certification and seal to validate compliance with West Virginia Code 5A-3-10a.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Vendor Preference Certificate.pdf | ||
| OneTimePurchaseRFQ.docx | DOCX document | |
| Final_ARFQ_0310_DNR1600000085_1_ARFQ_FORM.PDF | ||
| Exhibit A - pricing page.xlsx | XLSX spreadsheet | |
| TCA.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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