"Affidavit of Certification" - Connecticut

Affidavit of Certification is a legal document that was released by the Connecticut Department of Transportation - a government authority operating within Connecticut.

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AFFIDAVIT OF CERTIFICATION
This form must be signed and notarized for each owner upon which disadvantaged status is relied.
A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION
IS SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL,
INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR
ENTITY MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES
AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.
I _________________________ (full name printed), swear or affirm under penalty of law that I am
__________________ (title) of applicant firm ________________________ (firm name) and that I have read and
understood all of the questions in this application and that all of the foregoing information and statements submitted
in this application and its attachments and supporting documents are true and correct to the best of my knowledge,
and that all responses to the questions are full and complete, omitting no material information. The responses
include all material information necessary to fully and accurately identify and explain the operations, capabilities
and pertinent history of the named firm as well as the ownership, control, and affiliations thereof.
I recognize that the information submitted in this application is for the purpose of inducing certification approval by
a government agency. I understand that a government agency may, by means it deems appropriate, determine the
accuracy and truth of the statements in the application, and I authorize such agency to contact any entity named in
the application, and the named firm’s bonding companies, banking institutions, credit agencies, contractors, clients,
and other certifying agencies for the purpose of verifying the information supplied and determining the named
firm’s eligibility.
I agree to submit to government audit, examination and review of books, records, documents and files, in whatever
form they exist, of the named firm and its affiliates, inspection of its places(s) of business and equipment, and to
permit interviews of its principals, agents, and employees. I understand that refusal to permit such inquiries shall
be grounds for denial of certification.
If awarded a contract or subcontract, I agree to promptly and directly provide the prime contractor, if any, and the
Department, recipient agency, or federal funding agency on an ongoing basis, current, complete and accurate
information regarding (1) work performed on the project; (2) payments; and (3) proposed changes, if any, to the
foregoing arrangements.
I agree to provide written notice to the recipient agency or Unified Certification Program (UCP) of any material
change in the information contained in the original application within 30 calendar days of such change (e.g.,
ownership, address, telephone number, etc.).
I acknowledge and agree that any misrepresentations in this application or in records pertaining to a contract or
subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or
revocation of certification; suspension and debarment; and for initiating action under federal and/or state law
concerning false statement, fraud or other applicable offenses.
I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced
firm seeking certification as a Disadvantaged Business Enterprise (DBE). In support of my application, I certify
that I am a member of one or more of the following groups, and that I have held myself out as a member of the
group(s) (circle all that apply):
Female
Black American
Hispanic American
Native American
Asian- Pacific American
Subcontinent Asian American
Other (specify) ____________________________.
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AFFIDAVIT OF CERTIFICATION
This form must be signed and notarized for each owner upon which disadvantaged status is relied.
A MATERIAL OR FALSE STATEMENT OR OMISSION MADE IN CONNECTION WITH THIS APPLICATION
IS SUFFICIENT CAUSE FOR DENIAL OF CERTIFICATION, REVOCATION OF A PRIOR APPROVAL,
INITIATION OF SUSPENSION OR DEBARMENT PROCEEDINGS, AND MAY SUBJECT THE PERSON AND/OR
ENTITY MAKING THE FALSE STATEMENT TO ANY AND ALL CIVIL AND CRIMINAL PENALTIES
AVAILABLE PURSUANT TO APPLICABLE FEDERAL AND STATE LAW.
I _________________________ (full name printed), swear or affirm under penalty of law that I am
__________________ (title) of applicant firm ________________________ (firm name) and that I have read and
understood all of the questions in this application and that all of the foregoing information and statements submitted
in this application and its attachments and supporting documents are true and correct to the best of my knowledge,
and that all responses to the questions are full and complete, omitting no material information. The responses
include all material information necessary to fully and accurately identify and explain the operations, capabilities
and pertinent history of the named firm as well as the ownership, control, and affiliations thereof.
I recognize that the information submitted in this application is for the purpose of inducing certification approval by
a government agency. I understand that a government agency may, by means it deems appropriate, determine the
accuracy and truth of the statements in the application, and I authorize such agency to contact any entity named in
the application, and the named firm’s bonding companies, banking institutions, credit agencies, contractors, clients,
and other certifying agencies for the purpose of verifying the information supplied and determining the named
firm’s eligibility.
I agree to submit to government audit, examination and review of books, records, documents and files, in whatever
form they exist, of the named firm and its affiliates, inspection of its places(s) of business and equipment, and to
permit interviews of its principals, agents, and employees. I understand that refusal to permit such inquiries shall
be grounds for denial of certification.
If awarded a contract or subcontract, I agree to promptly and directly provide the prime contractor, if any, and the
Department, recipient agency, or federal funding agency on an ongoing basis, current, complete and accurate
information regarding (1) work performed on the project; (2) payments; and (3) proposed changes, if any, to the
foregoing arrangements.
I agree to provide written notice to the recipient agency or Unified Certification Program (UCP) of any material
change in the information contained in the original application within 30 calendar days of such change (e.g.,
ownership, address, telephone number, etc.).
I acknowledge and agree that any misrepresentations in this application or in records pertaining to a contract or
subcontract will be grounds for terminating any contract or subcontract which may be awarded; denial or
revocation of certification; suspension and debarment; and for initiating action under federal and/or state law
concerning false statement, fraud or other applicable offenses.
I certify that I am a socially and economically disadvantaged individual who is an owner of the above-referenced
firm seeking certification as a Disadvantaged Business Enterprise (DBE). In support of my application, I certify
that I am a member of one or more of the following groups, and that I have held myself out as a member of the
group(s) (circle all that apply):
Female
Black American
Hispanic American
Native American
Asian- Pacific American
Subcontinent Asian American
Other (specify) ____________________________.
1
I certify that I am socially disadvantaged because I have been subjected to racial or ethnic prejudice or cultural bias,
or have suffered the effects of discrimination, because of my identity as a member of one or more of the groups
identified above, without regard to my individual qualities.
I further certify that my personal net worth does not exceed $750,000, and that I am economically disadvantaged
because my ability to compete in the free enterprise system has been impaired due to diminished capital and credit
opportunities as compared to others in the same or similar line of business who are not socially and economically
disadvantaged.
I declare under penalty of perjury that the information provided in this application and supporting documents is true
and correct.
Executed on ______________(Date)
Signature ________________________________
(DBE Applicant)
NOTARY CERTIFICATE:
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