W912SR-19-R-0004_Draft_(27_Feb_19)-Redacted_for_FBO.pdf

(No Collect Calls)

(TYPE OR PRINT)

(TYPE OR PRINT)

31b. NAME OF CONTRACTING OFFICER

31a.UNITED STATES OF AMERICA

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30

EMAIL:

TEL:

31c. DATE SIGNED

(Print)

(Location)

(YY/MM/DD)

Buy American Act-Free Trade Agreements-Israeli Trade Act Certificate, Alternate I (Jan 2004)

Certification Regarding Responsibility Matters (Executive Order 12689)

The tax liability is finally determined.

The taxpayer is delinquent in making payment.

Listed End Products (Executive Order 13126) The Contracting Officer must list in paragraph (i)(1) any end products being acquired under this solicitation that are included in the List of Products Requiring Contractor Certification as to Forced or Indentured Child Labor, unless excluded at (b)

Listed end products

Certification If the Contracting Officer has identified end products and countries of origin in paragraph (i)(1) of this provision, then the offeror must certify to either (i)(2)(i) or (i)(2)(ii) by checking the appropriate block

Place of manufacture.

The contracting officer is to check a box to indicate if paragraph (k)(1) or (k)(2) applies.

Representation and Certifications e.g.

Ownership or Control of Offeror

Representation by Corporations Regarding Delinquent Tax Liability or a Felony Conviction under any Federal Law.

et seq

Field Name in WAWF Data to be entered in WAWF