RFP 170-4506-26 Attachment C Certification Sheet_FINAL.docx

Attachment C Proposer Information and Certification Sheet

Proposer Legal Business Name:

Address:

City:

State:

Postal Code (Zip):

Oregon Business Registry Number:

Entity Type (Ex: LLC):

State of Incorporation:

Authorized Representative Name:

Telephone Number:

Email Address:

Certifications

1. I understand and accept the requirements of Request number 170-4506-26. I agree to be bound by the Contract terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions Treasury has reserved for negotiations, as identified in Attachment A.

2. I acknowledge receipt of any and all Addenda to the Request.

3. I guaranty that the terms of the Proposal are valid for 120 days following the Closing.

4. If awarded the Contract, I agree to perform the scope of work and meet the performance standards included in the final, negotiated Contract’s Scope of Work.

5. My employer is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317, and 318 to the best of my knowledge.

6. My employer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, my employer does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business. If applicable, Proposer has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Treasury may not enter into a contract with an anticipated contract price of $150,000 or more with a Proposer that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

7. I, my employer, or any of my employer’s employees, agents, and subcontractors are not included on:

a. The “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or

b. The government-wide exclusions in the System for Award Management found at: https://www.sam.gov/portal/.

8. I certify that, there exists no actual or potential conflict between the business or economic interests of my employer, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the Request. If any changes occur with respect to my employer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing.

9. I certify that all contents of the Proposal (including any other forms or documentation, if required under the Request) and this Proposal Certification Sheet are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

10. I understand that any statement or representation made in response to the Request, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" (as defined by the Oregon False Claims Act, ORS 180.750(1)), made under Contract being a "false claim" (ORS 180.750(2)) subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

11. I acknowledge these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

I hereby certify that the above statements are true and correct to the best of my knowledge.

Authorized Representative Printed Name

Title

Authorized Signature

Date

Attachment C Proposer Information and Certification Sheet 170-4506-26 Template DOJ Approved: 01/22/19 image1.png image2.png