Debarment Certificate Form

DEBARMENT CERTIFICATE FORM

This Debarment Certificate (the Certificate) is made effective as of Effective Date: by and between Agency Name: with principal address at (the Agency) and Contractor Name: with principal address at (the Contractor).

RECITALS

WHEREAS, the Agency requires a certification from contractors that they are not debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal, state, or municipal agency; and

WHEREAS, the Contractor seeks to enter into contracts, purchase orders or other agreements with the Agency and agrees to provide a truthful and complete representation of its debarment status and related disclosures; and

WHEREAS, the parties desire to set forth the Contractor's certification obligations and the consequences of any false, omitted, or misleading statements with respect to debarment or exclusion status.

NOW, THEREFORE, in consideration of the mutual covenants set forth below, the parties agree as follows:

1. DEFINITIONS

For purposes of this Certificate the following terms have the meanings set forth below:

a) "Debarment" means an action taken by a government entity to exclude a person or entity from participation in government procurement or nonprocurement programs for a specified period because of causes such as conviction of or civil judgment for fraud, violation of statutes, or serious misconduct.

b) "Excluded" means listed by any governmental agency or authorized interagency system as debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from contracting or subcontracting.

2. CERTIFICATION OF NON-DEBARMENT

The Contractor hereby certifies, represents and warrants that, as of the Effective Date and continuing for the term of any Agreement with the Agency, the Contractor and any of its principals, officers, directors, managers, or owners:

1. The Contractor is not currently subject to debarment, suspension, voluntary exclusion, or declared ineligible by any federal, state, or local governmental authority.
2. The Contractor is not listed on any government exclusion list and has not been proposed for debarment by any governmental entity.
3. The Contractor will not knowingly engage any subcontractor or supplier that is debarred, suspended, or otherwise excluded without prior written approval of the Agency.

3. ENTITY TYPE

Individual    Corporation    Partnership    Other:

4. DISCLOSURE OF ADVERSE ACTIONS

Has the Contractor, or any principal of the Contractor, within the last ten (10) years been suspended, debarred, indicted, convicted, or subjected to any civil judgment or administrative determination that could bear on eligibility for contracting?

Yes    No

5. ONGOING DUTY TO NOTIFY

The Contractor shall notify the Agency in writing within calendar days of any change in status that would affect the certifications made herein, including any debarment, suspension, indictment, conviction, or other action that may render the Contractor ineligible to participate in covered transactions.

6. REPRESENTATIONS, WARRANTIES AND COVENANTS

The Contractor represents and warrants that all information provided in this Certificate is true, complete and correct. The Contractor covenants that it will maintain compliance with all applicable laws and shall promptly disclose to the Agency any event that would materially affect the Contractor's eligibility to contract with public agencies.

7. REMEDIES FOR FALSE CERTIFICATION

In the event that the Contractor makes a false, misleading, or incomplete certification, the Agency shall have the right to: (a) suspend performance and payments; (b) terminate any contract or purchase order for default; (c) require repayment of sums paid; (d) pursue claims for damages, penalties, or other remedies available at law or equity; and (e) refer the matter to appropriate government authorities for debarment or other administrative action.

8. INDEMNIFICATION

The Contractor shall indemnify, defend and hold harmless the Agency, its officers, agents and employees from and against any and all claims, losses, liabilities, costs and expenses (including reasonable attorneys' fees) arising from a breach of the Contractor's certifications, representations or warranties under this Certificate, including any false statements or omissions.

9. NOTICES

10. AMENDMENTS; WAIVER; COUNTERPARTS

This Certificate may be amended only by a written instrument executed by both parties. No failure or delay by any party in exercising any right shall operate as a waiver. This Certificate may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

Governing Law: This Certificate shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

Severability: If any provision of this Certificate is held to be invalid, illegal or unenforceable, the remaining provisions shall remain in full force and effect.

Entire Agreement: This Certificate, together with any referenced attachments or schedules, constitutes the entire agreement between the parties concerning the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

12. CERTIFICATION AND SIGNATURE

The undersigned, on behalf of the Contractor, certifies under penalty of law that the statements made in this Certificate are true and correct, that the signatory is fully authorized to execute this Certificate on behalf of the Contractor, and that the Contractor understands that false statements may subject the Contractor to penalties for fraud, contract termination, and other remedies.

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