Food Service Management Contract Form (Page 4 of 4) in pdf

Certification regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion

Contracts/Subcontracts

Each provider whose contract equals or exceeds $100,000 in federal monies must sign this

debarment certification prior to contract execution. Independent auditors who audit federal

programs regardless of the dollar amount are required to sign a debarment certification form.

Neither the Department of Elder Affairs nor its contract providers can contract with providers if

they are debarred or suspended by the federal government.

This certification is a material representation of fact upon which reliance is placed when this

contract is entered into. If it is later determined that the signed knowingly rendered an erroneous

certification, the Federal Government may pursue available remedies, including suspension

and/or debarment.

The provider shall provide immediate written notice to the contract manager at any time the

provider learns that its certification was erroneous when submitted or has become erroneous by

reason of changed circumstances.

The terms "debarred," "suspended," "ineligible," "person," "principal," and "voluntarily

excluded," as used in this certification, have the meanings set out in the Definitions and Coverage

sections of rules implementing Executive Order 12549 and 45 CFR (Code of Federal

Regulations), Part 76. You may contact the contract manager for assistance in obtaining a copy

of these regulations.

The provider further agrees by submitting this certification that, it shall not knowingly enter into

any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily

excluded from participation in this contract unless authorized by the Federal Government.

The provider further agrees by submitting this certification that it will require each subcontractor

of this contract whose payment will equal or exceed $100,000 in federal monies, to submit a

signed copy of this certification with each contract.

The Department of Elder Affairs and its contract providers may rely upon a certification of a

provider that is not debarred, suspended, ineligible, or voluntarily excluded from

contracting/subcontracting unless it knows that the certification is erroneous.

Page 2 of 2

Rev.7/28/15

Food Service Management Contract Form Page 4