U.S. Firm is a [check one]
Corporation LLC Partnership Sole Proprietor Other:
The U.S. Firm 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 U.S. Firm has not had filed against it an
involuntary petition under any bankruptcy, insolvency, or any similar law.
The U.S. Firm certifies that it complies with the USTDA Nationality, Source, and Origin Requirements and shall continue to
comply with such requirements throughout the duration of the USTDA-funded activity. The U.S. Firm acknowledges that the
USTDA Nationality, Source, and Origin Requirements apply to the delivery of goods and professional services funded by USTDA,
including, but not limited to the use of subcontractors. The U.S. Firm commits to notify USTDA and the Grantee if it becomes
aware of any change which might affect the U.S. Firm’s ability to meet the USTDA Nationality, Source, and Origin Requirements.
Neither the U.S. Firm 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 civil judgment rendered against them for: commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a federal, state, or local government contract or
subcontract; violation of federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating state or federal
criminal tax laws, or receiving stolen property.
Neither the U.S. Firm, 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 federal or state tax liens pending against the assets, property, or business of the U.S. Firm. The U.S. Firm 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.
U.S. Firm's Representations
U.S. Firm shall certify the following (or provide any explanation as to why any representation cannot be made):
The U.S. Firm 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
The U.S. Firm commits to notify USTDA and the Grantee if it becomes aware of any change in its status in the state in which it is
incorporated. USTDA retains the right to request an updated certificate of good standing at any time. (U.S. publicly traded
companies need not include Articles of Incorporation or Certificate of Good Standing.)
duly organized, validly existing and in good standing under the laws of the State of: 18.
The U.S. Firm has all the requisite corporate power and authority to conduct its business as presently conducted, to submit this
proposal, and if selected, to execute and deliver a contract to the Grantee for the performance of the USTDA Activity. The U.S.
Firm is not debarred, suspended, or to the best of its knowledge or belief, proposed for debarment or ineligible for the award of
contracts by any federal or state governmental agency or authority.
The U.S. Firm shall notify USTDA if any of the representations are no longer true, correct, and complete.
If U.S. Firm is Private or Other, please attach a copy of the U.S. Firm's Articles of Incorporation (or equivalent document)
and Certificate of Good Standing (or equivalent document).
22. Full Legal Name of U.S. Firm
U.S. Firm certifies that the information provided in this form is true, correct, and complete. U.S. Firm 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 U.S. Firm.
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