Grantee is a:
16.
17.
22. Date
Please attach a copy of the Grantee's Articles of Incorporation (or equivalent document) and Certificate of Good Standing
(or equivalent document) as well as an English translation of these documents.
20. Full Legal Name of Grantee
Grantee certifies that the information provided in this form is true, correct, and complete. Grantee understands and agrees that the U.S. Government may
rely on the accuracy of this information in processing a request to participate in a USTDA-funded activity. If at any time USTDA has reason to believe that
any person or entity has willfully and knowingly provided incorrect information or made false statements, USTDA may take action under applicable law.
The undersigned represents and warrants that he/she has the requisite power and authority to sign on behalf of the Grantee.
The Grantee has also included herewith, an English translation of such documentation. The Grantee commits to notify USTDA
if it becomes aware of any change in its status in the jurisdiction in which it is incorporated.
The Grantee has all the requisite corporate power and authority to conduct its business as presently conducted. The Grantee
is not debarred, suspended, or to the best of its knowledge or belief, proposed for debarment or ineligible for the award of
government contracts under the laws of the U.S. or any other law.
Neither the Grantee nor any of its directors and principal officers have, within the ten-year period preceding the submission of
these representations, been convicted of or had a judgment rendered against them for: commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a government contract or subcontract under the
laws of the U.S. or any other law; violation of antitrust statutes under the laws of the U.S. or any other law relating to the
submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making
false statements, tax evasion, violating criminal tax laws, or receiving stolen property.
Neither the Grantee, nor any of its directors and principal officers, is presently indicted for, or otherwise criminally or civilly
charged with, commission of any of the offenses enumerated in paragraph C above.
There are no tax liens pending against the assets, property, or business of the Grantee. The Grantee has not, within the three-
year period preceding the submission of these representations, been notified of any delinquent federal or state taxes in an
amount that exceeds US$3,000 for which the liability remains unsatisfied. Taxes are considered delinquent if (a) the tax
liability has been fully determined, with no pending administrative or judicial appeals; and (b) a taxpayer has failed to pay the
tax liability when full payment is due and required.
The Grantee has not commenced a voluntary case or other proceeding seeking liquidation, reorganization, or other relief with
respect to itself of its debts under any bankruptcy, insolvency, or other similar law. The Grantee has not had filed against it an
involuntary petition under any bankruptcy, insolvency, or any similar law.
The Grantee shall notify USTDA if any of the representations are no longer true, correct, and complete.
Grantee's Representations
Grantee shall certify the following (or provide any explanation as to why any representation cannot be made):
The Grantee has included herewith, a copy of its Articles of Incorporation (or equivalent charter or document issued by a
designated authority in accordance with applicable laws that provides information and authentication regarding the legal
status of an entity) and a Certificate of Good Standing (or equivalent document) issued within one (1) month of the date of
signature below under the laws of:
duly organized, validly existing and in good standing under the laws of:
15. Type of Business Entity (e.g., corporation, LLC, SA, JSC, LP, etc.)
Page 3 of 3
