Eligibility Certification Form

ELIGIBILITY CERTIFICATION FORM

Date:

WHEREAS

WHEREAS, Applicant Name: (the "Applicant") seeks certification of eligibility for participation in the Program or Contract described below; and

WHEREAS, Program Administrator / Provider Name: (the "Provider") requires Applicant to certify factual, financial and regulatory eligibility as a condition precedent to award, payment, or participation;

NOW, THEREFORE, in consideration of the Provider's review and possible award, the Applicant certifies the following under penalty of perjury and agrees to the terms set forth in this Eligibility Certification Form.

APPLICANT CONTACT INFORMATION

PROGRAM / CONTRACT IDENTIFICATION

CERTIFICATIONS OF ELIGIBILITY

By checking the boxes below and signing this form, the Applicant certifies that the statements are true, correct and complete to the best of the Applicant's knowledge and that the Applicant has the authority to make these certifications on behalf of the Applicant entity.

  Applicant is a lawful entity authorized to conduct business in the applicable jurisdiction and, if an individual, is a lawfully present person.

  Applicant is not debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation by any federal, state, or local agency, and will notify the Provider immediately if such status changes.

  Applicant has provided complete and accurate financial and ownership disclosures required for eligibility determination and will provide supporting documentation upon request.

SCOPE OF WORK

PAYMENT TERMS

Payments are due as set forth above. Late payments shall accrue the Late Payment Fee beginning on the first calendar day after the due date. The Provider may withhold certification, suspend performance or set off amounts where material misrepresentations affecting eligibility or payment are discovered.

TERM AND TERMINATION

Term Start Date:    Term End Date:

Either party may terminate this certification and any related agreement for convenience upon written notice as specified above. Termination for cause may be effected immediately where fraud, material misrepresentation, debarment or failure to perform occurs. Termination does not relieve Applicant of obligations accruing prior to termination.

CONFIDENTIALITY

All non-public information disclosed in connection with this certification and related evaluation is Confidential Information. Each party shall: (a) use Confidential Information solely for purposes of evaluation and performance under this certification; (b) protect it with at least the same degree of care as it uses for its own confidential information, but no less than reasonable care; and (c) not disclose it to third parties except to its employees or advisors who need to know and who are bound by confidentiality obligations. Confidentiality obligations survive termination for a period of three (3) years, except as otherwise required by law.

GOVERNING LAW

This Eligibility Certification Form and any disputes arising out of it shall be governed by the laws of the jurisdiction identified below without regard to conflict of law principles.

ENTIRE AGREEMENT

This document, together with any attachments, appendices and incorporated documents expressly referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous agreements, representations and understandings, whether written or oral. Any amendment must be in writing and signed by authorized representatives of both parties.

REMEDIES; AUDIT RIGHTS

The Provider may seek all available remedies, including repayment, set-off, suspension or debarment, for false statements or material noncompliance. Applicant shall retain and provide, upon reasonable request, documents supporting eligibility claims for a period of no less than three (3) years following final payment.

CERTIFICATION AND SIGNATURE

The undersigned certifies, under penalty of perjury or the equivalent applicable sanction, that the information provided is true, accurate and complete, and that the undersigned is authorized to bind the Applicant to the certifications and obligations contained herein.

Name of Certifying Official:    Title:

Authority to Bind Applicant:   I have the legal authority to execute this certification on behalf of the Applicant.

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