Form FDIC 3700/04A FDIC 3700/04A FDIC Contractor Representations and Certifications

OMB NUMBER: 3064-0072

EXPIRATION DATE: 11/30/2008

FDIC

Contractor

Representations and

Certifications

     

SUBMITTED BY

     

CONTRACTOR NAME

TABLE OF CONTENTS

Section

Page

Estimated Reporting Burden	3
Privacy Act Statement	3
1. Minority and Women-Owned Business Representations	4
2. Small Disadvantaged Business Certification	5
3. Certificate of Independent Price Determination	5
4. Contingent Fee Representation	6
5. Equal Opportunity Certification	6
6. Duplication of Cost	7
7. Clean Air and Water Certification	7
8. Certification and Disclosure Regarding Payments to Influence Certain Federal Transactions	8
9. Signature	9

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of information is estimated to average one-half hour per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0072), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

PRIVACY ACT STATEMENT

Collection of this information is authorized by the Federal Deposit Insurance Act, 12 U.S.C.) § 1819, 1821, and Executive Order 9397. This information will be primarily used to examine a contractor’s compliance with FDIC contracting regulations for potential FDIC contract awards and the information provided may be disclosed to licensing authorities by the FDIC in so examining the contractor’s compliance.

Information may also be disclosed to appropriate Federal, state, or local agencies for law enforcement purposes when a violation or possible violation of a civil or criminal law is apparent; to individuals involved in judicial or administrative proceedings; and to a Congressional office in response to an inquiry made at the individual’s request. Information may also be disclosed in accordance with the other routine uses set forth in the FDIC’s Financial Information System 30-64-0012. Furnishing the requested information, including your Social Security Number, is voluntary. However, failure to furnish all requested information may preclude you from receiving an FDIC contract.

T he following representations and certifications shall be executed by an official authorized to bind the offeror, and shall be returned with its proposal. These representations and certifications concern matters within the jurisdiction of an agency of the United States, and the making of a false, fictitious, or fraudulent statement may render the maker subject to prosecution under 18 United States Code (U.S.C.) § 1001, 1007, and 1014. For purposes of these representations and certifications, the Federal Deposit Insurance Corporation (FDIC) is considered an agency of the United States only with respect to its rights and remedies under 18 U.S.C. The offeror shall provide immediate written notice to the Contracting Officer, if, at any time prior to contract award, the offeror learns that one or more of the representations or certifications was erroneous when submitted or has become erroneous by reason of changed circumstances.

1. MINORITY AND WOMEN-OWNED BUSINESS REPRESENTATIONS

a. It is, it is not, a minority-owned business concern. A minority-owned business concern is defined as a firm in which at least 51% of the ownership and control is directly and unconditionally held by one or more minorities. A firm which is principally owned by another business entity or a trust (including employee stock ownership trusts) that is in turn owned and controlled by one or more minorities does not meet this definition. In the case of a firm which is a corporation, at least 51% of each class of voting stock outstanding, and 51% of the aggregate of all stock outstanding, must be unconditionally owned by one or more minorities. Additionally, the firm(s) management and daily business operations must be conducted by one or more of the qualifying minority owner(s). The minority individuals must have managerial experience of the extent and complexity needed to run the firm. A minority owner’s unexercised right to cause a change in the control of management of the firm does not constitute minority control and management, regardless of how quickly or easily the right could be exercised.

b. If a minority-owned business:

1. Check the appropriate box below indicating ethnicity.

Hispanic or Latino Not Hispanic or Latino

(2) Check the appropriate box below indicating racial category.

American Indian/Alaska Native Black or African American

Asian Native Hawaiian or Other Pacific Islander

c. It is, it is not, a women-owned business. A women-owned business is defined as a firm in which at least 51% of the ownership and control is directly or unconditionally held by one or more women. A firm which is principally owned by another business entity or by a trust (including employee stock ownership trusts) that is in turn owned and controlled by one or more women does not meet this definition. In the case of a firm which is a corporation, at least 51% of each class of voting stock outstanding, and 51% of the aggregate of all stock outstanding, must be unconditionally owned by one or more women. Additionally, the firm(s) management and daily business operations must be conducted by one or more women. The women must have managerial experience of the extent and complexity needed to run the firm. A women owner’s unexercised right to cause a change in control or management of the firm does not constitute minority control and management, regardless of how quickly or easily the right could be exercised.

d. If offeror is a minority or women-owned business, where did it hear about FDIC contracting opportunities.

Convention/Procurement Fair Minority and/or Women’s Organization

Current Solicitation Other (Explain) Personal Contact

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2. SMALL DISADVANTAGED BUSINESS CONCERN CERTIFICATION

It is, it is not, a small disadvantaged business concern that has been certified as a small disadvantaged business concern by the Small Business Administration, or it has filed an application with the Small Business Administration to be certified as a small disadvantaged business concern. A small disadvantaged business concern that has applied for but not yet received Small Business Administration certification may be entitled to treatment as a small disadvantaged business concern where certification can be obtained before the contract is awarded.

3. CERTIFICATE OF INDEPENDENT PRICE DETERMINATION

1. The offer certifies that:

1. The prices in this proposal have been arrived at independently, without, for the purposes of restricting competition, any consultation, communication, or agreement with any other offeror or competitor relating to (I) those prices, (ii) the intention to submit an offer or (iii) the methods or factors used to calculate the prices offered;

2. The prices in this proposal have not been and will not be knowingly disclosed by the offeror, directly or indirectly, to any other offeror or competitor before contract award unless otherwise required by law; and

3. No attempt has been made or will be made by the offeror to induce any other concern to submit or not to submit a proposal for the purpose of restricting competition.

b. Each signature on the proposal is considered to be a certification by the signatory that the signatory:

1. Is the person in the offeror’s organization responsible within that organization for determining the prices being offered in this proposal, and that the signatory has not participated and will not participate in any action contrary to a.(1) through a.(3) above, or

2. (i) Has been authorized, in writing, to act as agent for the following principals in certifying that those principals have not participated, and will not participate in any action contrary to subparagraphs a.(1) through a.(3) above

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(insert full name of person(s) in the offeror’s organization responsible or determining the prices offered in this proposal, and the title of his or her position in the offeror’s organization);

(ii) As an authorized agent, certifies that the principals named in subdivision b.(2)(I) above have not participated, and will not participate I, in any action contrary to subparagraphs a.(1) through a.(3) above; and (iii) As an agent, has not personally participated, and will not participate, in any action contrary to subparagraphs a.(1) through a.(3) above.

c. A proposal will not be considered for award where a.(1), a.(3) or b. above has been deleted or modified. If the offeror deleted or modifies a.(2) above, the offeror must furnish with its proposal a signed statement setting forth in detail the circumstances of the disclosure.

4. CONTINGENT FEE REPRESENTATION

Not applicable to proposals below $100,000 or for the acquisition of commercial items.

The offeror represents that except for full-time bona fide employees working solely for the offeror, the offeror (a) has, has not, employed or retained any person or company to solicit or obtain this contract; and (b) has, has not, paid or agreed to pay any person or company employed or retained to solicit or obtain this contract any commission, percentage, brokerage, or other fee contingent upon or resulting from the award of this contract. The offeror agrees to provide information relating to this Representation as requested by the Contracting Officer when either (a) or (b) herein is answered affirmatively. As used herein, “bona fide employee” means a person, employed by an offeror or contractor and subject to the offeror’s or the contractor’s supervision and control as to time, place, and manner of performance, who neither exerts nor proposes to exert improper influence to solicit or obtain FDIC contracts, nor holds out as being able to obtain any FDIC contract or contracts through improper influence.

4. EQUAL OPPORTUNITY CERTIFICATION

1. Have you participated in any contractual agreement which contained the Equal Employment Opportunity provisions prescribed in Executive Order (E.O.) 11246?

Yes No

2. Were you required pursuant to the rules and regulations of Equal Employment Opportunity (41 CFR 60-1) to file a compliance report as the result of such contractual agreement?

Yes No

3. Did you file the necessary compliance report? (If “yes” answer questions d. and e.)

Yes No

d. Name of agency requiring report. ____________________________.

e. When was report filed? ____________________________________.

f. Has any action been required of you to improve your compliance posture?

Yes No

g. Name and address of Government “Compliance Agency,” if known

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8. What is your current employment?

i. Have you prepared a written affirmative action compliance program?

Yes No

If “No,” the reason for this is:

Offeror is an agency or instrumentality of state or local government.

Offeror employs less than 50 persons.

Offeror has not been awarded a Federal contract or subcontract since July 1, 1968.

j. Data on subcontractors. (Use supplementary sheets where required.)

NAME OF SUBCONTRACTORS AND ADDRESSES

     	(1) (2) (3)
		Yes		Yes		Yes
		No		No		No
     	(1) (2) (3)
		Yes		Yes		Yes
		No		No		No

1. Previously held contracts subject to E.O. 11246.

2. Previously filed certificate of nonsegregated facilities.

3. Previously filed compliance report.

4. DUPLICATION OF COST

The offeror represents and certifies that any charges contemplated and included in its estimate of cost for performance are not duplicative of any charges against any other Government contract, subcontract, or other Government source.

4. CLEAN AIR AND WATER CERTIFICATION

(Applicable if the offer exceeds $100,000, or if the Contracting Officer has determined that orders under an indefinite quantity contract in any year will exceed $100,000 or a facility to be used has been the subject of a conviction under the Clean Air Act (42 U.S.C. § 1857 c-8 (c) (1)), or the Federal Water Pollution Control Act (33 U.S.C. § 1819 (c)) and is listed by the Environmental Protection Agency (EPA), or is not otherwise exempt.)

The offeror certifies as follows:

1. Any facility to be utilized in the performance of this proposed contract has, has not, been listed on the EPA list of violating facilities.

2. It will promptly notify the Contracting Officer, prior to award, of the receipt of any communication from the Director, Office of Federal Activities, EPA, indicating that any facility which it proposes to use for the performance of the contract is under consideration to be listed on the EPA list of violating facilities.

3. It will include substantially this certification, including this paragraph c., in every nonexempt subcontract.

4. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL

TRANSACTIONS

Applicable to contracts exceeding $100,000.

1. The offeror certifies that, to the best of its knowledge and belief, the following statements are true:

1. No Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on its behalf in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any Federal contract, grant, loan, or cooperative agreement.

Yes No

2. No nonappropriated funds (including profit or fee received under a covered Federal Transaction) have been paid, or will be paid, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on its behalf in connection with the solicitation associated with this certification.

Yes No

If the offeror has checked the “No” box at 8a. (2) above, indicating that any funds other than Federal appropriated funds (including profit or fee received under a covered Federal Transaction) have been paid, or will be paid, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress on his or her behalf in connection with this solicitation, the offeror shall complete and submit, with its offer, OMB Standard Form LLL, “Disclosure of Lobbying Activities” (available upon request) to the Contracting Officer.

b. The offeror certifies that it will include the language of this certification in all subcontract awards at any tier and require that all recipients of subcontract awards in excess of $100,000 shall certify and disclose accordingly.

c. Submission of this certification and disclosure, and when required, a completed OMB Standard Form LLL is a prerequisite for making or entering into this contract imposed by 31 U.S.C. § 1352. Any person who makes an expenditure prohibited under the contract provision entitled “Limitation on Payments to Influence Certain Federal Transactions” in the FDIC General Provisions, or who fails to file or amend the disclosure form to be filed or amended with this certification, shall be subject to a civil penalty of not less than $10, 000, and not more than $100,000, for each failure.

9. SIGNATURE

By signature hereto, the offeror certifies that all of the representations and certifications contained in its proposal are complete and accurate as required by this solicitation, and that it is aware of the penalty prescribed in 18 U.S.C. § 1001 for making false statements in proposals. The offeror also agrees to notify the FDIC in writing, within 10 days, after discovering that it or any person performing services under an FDIC contract has any of the disqualifying conditions contained within the representations and certifications. Such notification shall contain a detailed description of the disqualifying condition and may include a statement of how the offeror intends to resolve such condition. Further, the offeror by signature hereto gives express authorization and consent to the FDIC for the FDIC to release information contained herein to licensing authorities in the FDIC’s examination of the contractor’s compliance with FDIC non-ethics contracting regulations.

SOLICITATION NUMBER      
NAME OF OFFEROR (Please print or type)      	OFFEROR’S TAX IDENTIFICATION NUMBER (TIN)      
TITLE      
NAME OF OFFEROR’S FIRM      	OFFEROR’S TELEPHONE NUMBER (     )      
OFFICE ADDRESS      
CITY      	STATE      	ZIP CODE      
SIGNATURE		DATE SIGNED      

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