Form Hud-5369-A - Representations, Certifications, And Other Statements Of Bidders - Public And Indian Housing Programs Page 2
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4Representations, Certifications,
and Other Statements of Bidders
Public and Indian Housing Programs
Table of Contents
(iii) As an agent, has not personally participated, and will
Clause
Page
not participate in any action contrary to subparagraphs (a)(1)
1.
Certificate of Independent Price Determination
1
through (a)(3) above.
2.
Contingent Fee Representation and Agreement
1
(c) If the bidder deletes or modifies subparagraph (a)2 above, the
3.
Certification and Disclosure Regarding Payments
bidder must furnish with its bid a signed statement setting forth in
to Influence Certain Federal Transactions
1
detail the circumstances of the disclosure.
4.
Organizational Conflicts of Interest Certification
2
[ ] [Contracting Officer check if following paragraph is applicable]
5.
Bidder's Certification of Eligibility
2
(d) Non-collusive affidavit. (applicable to contracts for construction
6.
Minimum Bid Acceptance Period
2
and equipment exceeding $50,000)
7.
Small, Minority, Women-Owned Business Concern
(1) Each bidder shall execute, in the form provided by the PHA/
Representation
2
IHA, an affidavit to the effect that he/she has not colluded with any
8.
Indian-Owned Economic Enterprise and Indian
other person, firm or corporation in regard to any bid submitted in
Organization Representation
2
response to this solicitation. If the successful bidder did not submit
9.
Certification of Eligibility Under the Davis-Bacon Act
3
the affidavit with his/her bid, he/she must submit it within three (3)
working days of bid opening. Failure to submit the affidavit by that
10. Certification of Nonsegregated Facilities
3
date may render the bid nonresponsive. No contract award will be
11. Clean Air and Water Certification
3
made without a properly executed affidavit.
12. Previous Participation Certificate
3
(2) A fully executed "Non-collusive Affidavit" [ ] is, [ ] is not
13. Bidder's Signature
3
included with the bid.
2.
Contingent Fee Representation and Agreement
1.
Certificate of Independent Price Determination
(a) Definitions. As used in this provision:
(a) The bidder certifies that--
"Bona fide employee" means a person, employed by a bidder
(1) The prices in this bid have been arrived at independently,
and subject to the bidder's supervision and control as to time, place,
without, for the purpose of restricting competition, any consultation,
and manner of performance, who neither exerts, nor proposes to
communication, or agreement with any other bidder or competitor
exert improper influence to solicit or obtain contracts nor holds out
relating to (i) those prices, (ii) the intention to submit a bid, or (iii) the
as being able to obtain any contract(s) through improper influence.
methods or factors used to calculate the prices offered;
"Improper influence" means any influence that induces or tends
(2) The prices in this bid have not been and will not be
to induce a PHA/IHA employee or officer to give consideration or to
knowingly disclosed by the bidder, directly or indirectly, to any other
act regarding a PHA/IHA contract on any basis other than the merits
bidder or competitor before bid opening (in the case of a sealed bid
of the matter.
solicitation) or contract award (in the case of a competitive proposal
(b) The bidder represents and certifies as part of its bid that, except
solicitation) unless otherwise required by law; and
for full-time bona fide employees working solely for the bidder, the
(3) No attempt has been made or will be made by the bidder to
bidder:
induce any other concern to submit or not to submit a bid for the
(1) [ ] has, [ ] has not employed or retained any person or
purpose of restricting competition.
company to solicit or obtain this contract; and
(b) Each signature on the bid is considered to be a certification by
(2) [ ] has, [ ] has not paid or agreed to pay to any person or
the signatory that the signatory--
company employed or retained to solicit or obtain this contract any
(1) Is the person in the bidder's organization responsible for
commission, percentage, brokerage, or other fee contingent upon or
determining the prices being offered in this bid or proposal, and that
resulting from the award of this contract.
the signatory has not participated and will not participate in any
(c) If the answer to either (a)(1) or (a)(2) above is affirmative, the
action contrary to subparagraphs (a)(l) through (a)(3) above; or
bidder shall make an immediate and full written disclosure to the
(2) (i)
Has been authorized, in writing, to act as agent for the
PHA/IHA Contracting Officer.
following principals in certifying that those principals have not
(d) Any misrepresentation by the bidder shall give the PHA/IHA the
participated, and will not participate in any action contrary to
right to (1) terminate the contract; (2) at its discretion, deduct from
subparagraphs (a)(l) through (a)(3) above.
contract payments the amount of any commission, percentage,
_______________________________________________ [insert
brokerage, or other contingent fee; or (3) take other remedy
full name of person(s) in the bidder's organization responsible for
pursuant to the contract.
determining the prices offered in this bid or proposal, and the title of
3.
Certification and Disclosure Regarding Payments to
his or her position in the bidder's organization];
Influence Certain Federal Transactions
(applicable to
(ii) As an authorized agent, does certify that the principals
contracts exceeding $100,000)
named in subdivision (b)(2)(i) above have not participated, and will
(a) The definitions and prohibitions contained in Section 1352 of
not participate, in any action contrary to subparagraphs (a)(1)
title 31, United States Code, are hereby incorporated by reference
through (a)(3) above; and
in paragraph (b) of this certification.
Page1 of 3
form HUD-5369-A (11/92)
Previous edition is obsolete
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