UPC 121556 C-104 form.pdf
PDF 97 KB Posted
- Attached to
- Construction, University Drive Bike Lanes
- Solicitation number
- IFB-114424
- Issued by
- Fairfax County, Virginia
About this file
This is a C-104 form—a non-collusion affidavit required by the Commonwealth of Virginia Department of Transportation for Federal Highway Administration (FHWA) projects. The form must be completed, signed, and submitted with all bids; failure to do so may result in bid rejection. Each principal of a joint venture bid must submit a separate form. The document requires the bidder to affirm, either through a notarized affidavit or an unsworn declaration under penalty of perjury, that the firm and its officers, agents, or employees did not engage in collusion, combination, or arrangement with other parties to restrain free and competitive bidding in violation of the Sherman Act or Virginia's Governmental Frauds Act and related statutes.
The form provides two options for attestation: a traditional notarized affidavit format with space for signature, title, notary certification, and commission expiration date, or an unsworn declaration format signed under penalty of perjury. The document is designated for UPC 121556 and serves as compliance documentation for bidders on Commonwealth Transportation Board contracts, ensuring adherence to federal and state antitrust and anti-fraud regulations.
View the file
Other files
Show all 49
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
I
Form C-104 Rev. 7-13-05
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF TRANSPORTATION
PROJECT:
FHWA:
This form must be completed, signed and returned with bid; and failure to do so may result in the rejection of your bid. THE CONTRACTOR SHALL AFFIRM THE FOLLOWIN G STATEMENT EITHER BY SIGNING
THE AFFIDAVIT AND HA VING IT NOTARIZED OR BY SIGNING THE UNSWORN DECLARATION
UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES. A SEPARATE FORM
MUST BE SUBMITTED BY EACH PRINCIPAL OF A JOINT VENTURE BID.
STATEMENT, In preparation and submission of this bid, I, the firm, corporation or officers, agents or employees thereof did not, either directly or indirectly, enter into any combination or arrangement with any persons, firm or corporation or enter into any agreement, participate in any collusion, or otherwise take any action in the restraint of free, competitive bidding in violation of the Sherman Act (15 U.S.C. Section 1) or Article 1.1 or Chapter 12 of Title 18.2 (Virginia Governmental Frauds Act), Sections 59.1-9.1 through 59.1-
9.17 or Sections 59.1-68.6 through 59.1-68.8 of the Code of Virginia.
AFFIDAVIT
The undersigned is duly authorized by the bidder to make the foregoing statement to be filed with bids submitted on behalf of the bidder for contracts to be let by the Commonwealth Transportation Board.
Signed at County (City), STATE
, this day of , 20
(Name of Firm) By:
(Signature) Title (print) STATE of COUNTY (CITY) of To-wit:
, a Notary Public in and for the State and County(City) aforesaid, hereby certify that this day personally appeared before me and made oath that he is duly authorized to make the above statements and that such statements are true and correct.
Subscribed and sworn to before me this day of , 20
My Commission expires Notary Public
OR
UNSWORN DECLARATION
The undersigned is duly authorized by the bidder to make the foregoing statement to be filed with bids submitted on behalf of the bidder for contracts to be let by the Commonwealth Transportation Board.
Signed at , this day of , 20 County (City), STATE
By:
(Name of Firm) (Signature) Title (print)
| Text1: UPC 121556 |
| Text2: |
| Text3: |
| Text4: |
| Text5: |
| Text6: |
| Text7: |
| Text8: |
| Text9: |
| Text10: |
| Text11: |
| Text12: |
| Text13: |
| Text14: |
| Text15: |
| Text16: |
| Text17: |
| Text18: |
| Text19: |
| Text20: |
| Text21: |
File details come from the government source that posted it. Updated .