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FDIC 3700/04A (4-10) Page 1

FDIC

Contractor

Representations and

Certifications

SUBMITTED BY

CONTRACTOR NAME

OMB NUMBER: 3064-0072

EXPIRATION DATE: 03/31/201

FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS

FDIC 3700/04A (4-10) Page 2

TABLE OF CONTENTS

Section Page

Estimated Reporting Burden ................................................................................................................... 3

Privacy Act Statement ............................................................................................................................. 3

1. Certificate of Registration in Central Contract Registration (CCR) .................................................... 4

2. Certificate of Independent Price Determination.................................................................................. 4

3. Contingent Fee Representation.......................................................................................................... 5

4. Equal Opportunity Certification........................................................................................................... 6

5. Certification and Disclosure Regarding Payments to Influence

Certain Federal Transactions ..........................................................................................................

6. Signature ............................................................................................................................................ 7

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS

FDIC 3700/04A (4-10) Page 3

ESTIMATED REPORTING BURDEN

Public reporting burden for this collection of info rmation is estimated to average one-half hour per response,

including the time for revie wing the in structions, searching existing data source s, gathering and maintai ning

the data nee ded, and co mpleting and reviewing the colle ction of information. Send comm ents regarding this

burden estimate or any other a spect of this colle ction of information, including suggestions for re ducing this

burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation,

550 17

Street, N.W., Wa shington, D. C. 20429; and to the Office of Manag ement and Bu dget, Paperwork

Reduction Project (3064-0072), Washington, D. C. 2 0503. An ag ency m ay no t cond uct or sponsor, a nd a

person i s not requi red to respond to, a colle ction of information unle ss it di splays a currently valid OMB

control number.

PRIVACY ACT STATEMENT

Collection of this informati on is autho rized by the Federal Deposit Insurance Act, 12 U.S.C.) § 181 9, 1821,

and Executive Order 9397. This information will be primarily used to examine a contractor’s compliance with

FDIC contracting regul ations fo r pote ntial FDIC contract awards an d the i nformation p rovided m ay be

disclosed to licensing authorities by the FDIC in so examining the contractor’s compliance.

Information may also b e discl osed to appropri ate Fede ral, stat e, or local a gencies for l aw enfo rcement

purposes when a violation or possible violation of a civil or criminal law is a pparent; to individuals involve d in

judicial or ad ministrative proceedings; a nd to a Cong ressional office i n response to an i nquiry made at t he

individual’s request. Information may a lso be disclosed in accordance with the other routine uses set forth in

the FDIC’s Fi nancial Info rmation Syste m 30 -64-0012. Furnishing the requested info rmation, incl uding your

Social Security Number, is voluntary. Howeve r, failure to furnish all requested information may preclude you

from receiving an FDIC contract.



FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS

FDIC 3700/04A (4-10) Page 4

The following representations and certifications shall be executed by an official authorized to

bind the offeror,

and shall be returned with its propo sal. These representations and certifications concern matters within the

jurisdiction of an agency of the United States, and t he ma king of a fal se, fictit ious, or frau dulent statement

may render the maker subject to prosecution under 18 United States Code (U.S.C.) § 1001, 1007, and 1 014.

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 t he representations or cert ifications was erroneous when su bmitted or

has become erroneous by reason of changed circumstances.

1. CERTIFICATION OF REGISTRATION IN CENTRAL CONTRACTOR REGISTRATION (CCR)

a. The offeror certifies that it is registered in the Central Contractor Registration (CCR) at www.CCR.gov

and that all information in CCR is correct, including its socio-economic status.

Yes No

An offeror that marks “No” must also complete the certification in paragraph b.

b. The offeror certifies that it is in the process of registering in the Central Contractor Registration (CCR)

at www.CCR.gov

, and will enter correct information in CCR, including its socio-economic status.

Yes No

c. The socio-economic groups in CCR are as follows:

Wome n-Owned Business

Minority-O wned Business

Small Disadvantaged Business

For Minority-Owned Businesses, the ethnic/racial categories are as follows:

Asian-Pacific American Owned

Subcontinent Asian (Asian-Indian) American Owned

Black American Owned

Hispanic American Owned

Native American Owned

Other than one of the preceding

2. CERTIFICATE OF INDEPENDENT PRICE DETERMINATION

a. The offer certifies that:

(1) The p rices i n this p roposal have been arrive d at independently, without, for the pu rposes of

restricting competition, any consultation, communication, or agre ement with a ny other offeror or

competitor relating to (I) those pri ces, (ii) the in tention to submit an offer or (ii i) the method s or

factors used to calculate the prices offered;

(2) The pri ces in this pro posal have not b een an d will not be kno wingly disclo sed by the offeror,

directly or in directly, to any other offe ror or competitor before contra ct award unle ss oth erwise

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.

FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS

FDIC 3700/04A (4-10) Page 5

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 thi s propo sal, a nd that the signatory h as not parti cipated 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

(insert full name of person(s) in the offeror’s organization responsible for 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.

(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.

3. CONTINGENT FEE REPRESENTATION

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

The offeror represents th at except for full-time bo na fide empl oyees working solely for th e offero r, the

offeror ( a)

has has not employed o r retained a ny perso n or company to soli cit or obt ain this

contract; and (b)

has has not paid or agreed to pay any person or company employed or retained

to solicit or o btain this contract any commission, percentage, brokerage, or other fee contingent upon or

resulting fro m the award of this cont ract. Th e offe ror ag rees to provide i nformation relating to this

Representation a s requested by the Contracting Officer when eithe r (a) o r (b) he rein is a nswered

affirmatively. As used herein, “bona fide employee” means a person employed by an offeror or contractor

and subject to the offe ror’s or the contractor’s supervision an d control as to time, pla ce and manner of

performance, wh o n either exert s no r proposes to exert imp roper influ ence to soli cit o r obtain F DIC

contracts nor holds out as being able to obtain any FDIC contract or contracts through improper influence.

FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS

FDIC 3700/04A (4-10) Page 6

4. EQUAL OPPORTUNITY CERTIFICATION

The offeror represents that:

a. It

has has not participated in a previous contract or subcontract subject to the Equal

Opportunity clause of this solicitation;

b. It

has has not filed all required compliance reports; and

c. Representations indicating submission of required compliance reports, signed by proposed

subcontractors, will be obtained before subcontract awards.

The offeror also represents that:

d. It

has developed and has on file has not developed and does not have on file, at each

establishment, affirmative action programs required by the rules and regulations of the Secretary of

Labor (41 CFR 60-1 and 60-2); or

e. It

has not previously had contracts subject to the written affirmative action programs requirement of

the rules and regulations of the Secretary of Labor.

5. CERTIFICATION AND DISCLOSURE REGARDING PAYMENTS TO INFLUENCE CERTAIN FEDERAL

TRANSACTIONS

Applicable to contracts exceeding $100,000

a. Definitions. As u sed in t his provision “L obbying contact” h as the m eaning provided at 2 U.S.C. §

1602(8). The term s “age ncy,” “i nfluencing o r attemp ting to influe nce,” “officer or

Hmployee of DQ

agency,” “p

erson,” “reasonable compensation,” and “regularly employed” are defined in clause

7.3.2-58 entitled “Limitation on Payments to Influence Certain Federal Transactions.”

b. Prohibition. The prohibiti on and exce ptions contained in clause 7.3.2-58 e ntitled “Limitation on

Payments to Influen ce Certain Federal Tra nsactions” are he reby inco rporated by refere nce in thi s

provision.

c. Certification. The offeror, by signing its offer, here by certifies to the best of its knowledge and belief

that no Fede ral appropriated funds have been p aid or will be p aid to any person fo r influe ncing or

attempting to influence an officer o r employee of a ny agency, a Member of Congress, an officer o r

employee of Congress, or an employee of a Member of Congress on its behalf in connection with the

awarding of this contract.

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FDIC CONTRACTOR REPRESENTATIONS AND CERTIFICATIONS

FDIC 3700/04A (4-10) Page 7

d. Disclosure. If any re gistrants under the Lobbying Disclosure Act of 1995 have made a l obbying

contact on behalf of the offeror with respect to this contract, the offeror shall complete and submit,

with its offer, OMB Standard Form LLL, Disclosure of Lobbying Activities, to provide the name of

the re gistrants. Th e offero r ne ed not report regularly employed officers or employees of the

offeror to whom payments of reasonable compensation were made.

e. Penalty. Submission of this ce rtification and disclo sure is a prere quisite for m aking or ente ring

into this contract imposed by 31 U.S.C. §1352. Any person who makes an expenditure prohibited

under this provision or who fails to file or amend the disclosure required to be filed or amended by

this provis ion, s hall be subject to a civil penalty of not les s than $10,000, and not more than

$100,000, for each such failure.

6. SIGNATURE

By signature hereto, the offeror certifies that all of th e representations and certifications contained in it s

proposal are complete an d accurate a s required by th is 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, withi n 10 days, after discove ring that it or a ny person pe rforming services under an

FDIC contra ct ha s any of the di squalifying conditions contained withi n the representations a nd

certifications. Such notification shall contain a detai led description of the disqual ifying 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 lice nsing authorities in th e 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 DATA UNIVERSAL NUMBERING

SYSTEM (DUNS) NUMBER

GDJ

TITLE

NAME OF OFFEROR’S FIRM

OFFEROR’S TELEPHONE NUMBER

OFFICE ADDRESS

CITY

STATE

ZIP CODE

SIGNATURE

DATE SIGNED

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