Form 5430-001
(November 2011)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
SELF CERTIFICATION CLAUSE
BIDDERS STATEMENT
Sale Name
Sale Number
The bidder represents that he is is not a small business concern as defined by 13 CFR Ch. 1 Part 121.
(Date)
(Printed Name of Bidder)
Signature of Bidder
Title 18 USC, sec. 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the
United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction.
INSTRUCTIONS
In order to qualify for a set-aside sale, all bidders must certify to being
a small business concern by submitting an executed Self Certification
Clause.
The date on the Self Certification Clause and the sale date must be the
same.
A Self Certification Clause must accompany the deposit to qualify for
each set-aside sale. After a sale award is made, the Self Certification
Clause will be immediately returned, with the deposit, to the unsuccessful
bidders but may be resubmitted to qualify for other set-aside sales offered
on the same date.
The Self Certification Clause submitted by the successful bidder will
be retained by the Bureau of Land Management.
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