Attachment 4 Self-Certification for Antimafia.pdf

100 KB Posted

Attached to
Darby Military Community Construction Multiple Award Task Order (MATOC) Recompete
Solicitation number
W58D2M24R0003
Issued by

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Written by GovTribe AI ·

This document is a self-certification form for antimafia communication regarding an individual's position within a company bidding on a contract opportunity. The form requires the individual to declare under penalty of perjury that they do not have any prohibitions, decertifications or suspensions under Article 67 of Legislative Decree no. 159 of September 6, 2011. It also informs the individual that their personal data collected will be processed, including with IT systems, exclusively for the procedure for which this declaration is made.

The related federal contract opportunity is a solicitation for the Darby Military Community Construction Multiple Award Task Order (MATOC) Recompete. The solicitation number is W58D2M24R0003 and is being issued by the Department of the Army Materiel Command Army Contracting Command. The opportunity type is a solicitation but no further details are provided regarding required products or services, response dates, pricing terms, or set asides.

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W912PF23R0005 ATTACHMENT 5

Self-certification for Antimafia communication

Autocertificazione della comunicazione antimafia

Dichiarazione sostitutiva di certificazione (D.P.R. n. 445 del 28.12.2000)

Il/la sottoscritto/a (nome e cognome) _______________________________ C.F._________________ nato/a _______________________________ Prov. _________ il ______________ residente a

________________________ Prov. _____ in via/piazza ____________________

_______________________________ n. ____, in qualità di (carica ricoperta) ___________ dell’impresa (indicare la denominazione) _______________________________________________ C.F. __________________ avente la sede in _________________________ Prov. di __________ Via ___________________________ n. ______ consapevole delle sanzioni penali in caso di dichiarazioni false e della conseguente decadenza dai benefici eventualmente conseguiti (ai sensi degli artt. 75 e 76 D.P.R. 445/2000) sotto la propria responsabilità

DICHIARA

che nei propri confronti non sussistono le cause di divieto, di decadenza o di sospensione di cui all’art. 67 del D.lgs. n. 159 del 06/09/2011.

Il/la sottoscritto/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di dati personali) che i dati personali raccolti saranno trattati, anche con strumenti informatici, esclusivamente nell’ambito del procedimento per il quale la presente dichiarazione viene resa.

data firma leggibile del dichiarante (2)

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