SIMPLIFIED SECTION 889 FORM BLANK.pdf

SECTION 889 COMPLIANCE FORM

References:

a. FAR 52.204-24 through 26

b. DPC Memo “Governmentwide Commercial Purchase Card Guidance related to Implementation of the Section 889(a)(1)(B) Prohibition on Contracting with Entities Using Certain Telecommunications and Video Surveillance Services or Equipment”

Representation.

The Merchant represents that—

• It WILL WILL NOT provide telecommunication equipment or services from the following companies or any of their subsidiaries: Huawei Technologies Company, ZTE Corporation, Hytera Communications Corporation, Hangzhou Hikvision Digital Technology Company, or Dahua Technology Company.

• It DOES DOES NOT use telecommunication equipment or services from the following companies or any of their subsidiaries: Huawei Technologies Company, ZTE Corporation, Hytera Communications Corporation, Hangzhou Hikvision Digital Technology Company, or Dahua Technology Company.

Merchant Name

Merchant’s Authorized Representative

Authorized Representative Signature

If vendor indicates WILL or DOES, then review will be required by a Contracting Officer prior to purchase.

Contracting Officer Approval I have reviewed and determined procurement through this vendor is authorized.

Contracting Officers Name

Signature