B08 - Attachment 3 Tax-and-Felony-Representation-Form.pdf

Representations under DoD Assistance Agreements: Appropriations Provisions on Tax Delinquency and Felony Convictions

The applicant is ( ) is not ( ) a “Corporation” meaning any entity, including any institution of higher education, other nonprofit organization, or for-profit entity that has filed articles of incorporation.

If the applicant is a “Corporation” please complete the following representations:

(1) The applicant represents that it is ( ) is not ( ) a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

(2) The applicant represents that it is ( ) is not ( ) is not a corporation that was convicted of a criminal violation under any Federal law within the preceding 24 months.

NOTE: If an applicant responds in the affirmative to either of the above representations, the applicant is ineligible to receive an award unless the agency suspension and debarment official (SDO) has considered suspension or debarment and determined that further action is not required to protect the Government’s interests. The applicant therefore should provide information about its tax liability or conviction to the agency’s SDO as soon as it can do so, to facilitate completion of the required considerations before award decisions are made.

Sign:___________________________________

Date:____________________________________

Print Name and Position:______________________________________________