S03 Solicitation Attachment D Self-Certifications of Affiliation.docx
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- Attached to
- Q403-MDE International Federal contract opportunity
- Solicitation number
- 36C10X22R0004
About this file
This document contains a self-certification of affiliation form for offerors responding to solicitation number 36C10X21R0070 from the Department of Veterans Affairs for medical disability examinations. Offerors must disclose any affiliates as defined in the document and certify whether they have any affiliates that meet the criteria of a direct parent-subsidiary relationship, current or recent joint venture participation, common ownership or parent entity, or shared major shareholders or owners of more than 5%. By signing, offerors agree to notify the contracting officer of any changes to the accuracy of the certification prior to award.
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SOLICITATION ATTACHMENT D: Self Certifications of Affiliation
VA SOLICITATION NO. 36C10X21R0070
MEDICAL DISABILITY EXAMINATIONS
As stated in the FAR 52.212-1 supplement to this solicitation, the Government will not award contracts within the same region to one or more offerors who are “affiliates” of each other based on the definition stated here. For purposes of this solicitation, two entities shall be deemed to be “affiliates” of one another when one or more of the following circumstances applies:
· The entities are in a direct parent/subsidiary relationship, meaning that one of the entities is a “major shareholder or owner” of the other or of a parent entity of the other.
· The entities are currently participating or have participated in the one-year period immediately preceding solicitation closing, in any joint venture.
· The entities are organized under a common owner or parent entity.
· The entities have one or more major shareholders or owners in common.
For purposes of the bulleted categories identified above, “major shareholder or owner” is defined as one who owns more than a 5% share or interest in an entity.
I hereby certify on behalf of ______________________ (“offeror”) that as of the date indicated below (CHECK ONE BLOCK AS APPROPRIATE):
_______The offeror does not have any “affiliates” that meet any of the definitions stated above.
_______The offeror has one or more “affiliates” that meet one or more of the definitions stated above; and I have furnished with the offeror’s proposal full details concerning the identity of all the offeror’s affiliates, and the nature of the offeror’s relationships with each of the affiliates identified.
By signing below, I also certify that (1) I am duly authorized to bind the offeror; and (2) the offeror will notify the Contracting Officer for VA SOLICITATION NO. [Solicitation #] of any changes affecting the accuracy of my responses above, which occur at any time prior to notification of award being made under VA SOLICITATION NO. [Solicitation #]. By signing I acknowledge that any false statement made in connection with any part of this certification is subject to penalties under 18 USC 1001 and other federal statutes.
| SIGNATURE: | _______________________________________ |
| TITLE: | _______________________________________ |
| DATE: | _______________________________________ |
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