Evidence of Responsibility and Independent Price Determination Form

______, by signing this form, hereby:

(Enter company name)

  1. Eligibility to Receive Award - certifies it is qualified and eligible to receive an award for the provision of [describe goods or services] under applicable laws and regulations of the United States andJordan.
  1. Source/Nationality – certifies it meets the USAID Geographic Code 937 requirements, that it is indeed a legally registered entity/company in either Jordan, the United States or a USAID-designated Geo Code 937 developing country (refer to USAID ADS 310maa for the list of developing countries: .)
  1. Authorized Negotiators - confirms our offer, in response to this solicitation, may be discussed with any of the following individuals:

Name/Title / Address / Telephone / E-mail
  1. Adequate Financial Resources - confirms it has adequate financial resources to implement this contract.
  1. Ability to Comply - Having taken into consideration all current and anticipated other business commitments, will able to comply with the proposed terms and delivery schedule for this project.
  1. Conflict of Interest –confirms it has not offered gifts, payments or other remuneration, either directly or indirectly, to officials of FHI360 or the LENS Project in attempt to influence decisions or actions with respect to this solicitation.
  1. Record of Performance, Integrity and Business Ethics - certifies that it and/or any of its Principals are not presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any donor agency; and have not, within a three-year period preceding this proposal, been convicted of or had a judgment rendered against them for commission of fraud or a criminal offense; and have not, within a three-year period preceding this proposal, had one or more contracts terminated for default by any donor agency.
  1. Certification Regarding Terrorism Financing - certifies that it, or anyof its principals, are not on the U.S. Department of Treasury Office of Foreign Assets Control (OFAC) Specially Designated Nationals (SDN) List and is eligible to participate in this solicitation.
  1. Organization, Experience, Accounting, Operational Controls, and Technical Skills - certifies it has the necessary organization, experience, accounting and operational controls, and technical skills, or the ability to obtain them.
  1. Equipment and Facilities– confirms has the necessary production, construction, and technical equipment and facilities, or the ability to obtain them.
  1. Certification of Independent Price Determination – certifies:
  1. The prices in this offer have been arrived at independently, without, for the purpose of restricting competition, any consultation, communication or agreement with any other offeror, including but not limited to subsidiaries or other entities in which offeror has any ownership or other interests, or any 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 offer have not been and will not be knowingly disclosed by the offeror, directly or indirectly, to any other offeror, including but not limited to subsidiaries or other entities in which offeror has any ownership or other interests, or any competitor before bid opening (in the case of a sealed bid solicitation) or contract award (in the case of a negotiated or competitive solicitation) unless otherwise required by law.
  3. No attempt has been made or will be made by the offeror to induce any other concern or individual to submit or not to submit an offer for the purpose of restricting competition or influencing the competitive environment.
  4. Each signature on the offer is considered to be a certification by the signatory that the signatory:
  5. Is the person in the offeror’s organization responsible for determining the prices being offered in this bid or proposal and that the signatory has not participated and will not participate in any action contrary to subparagraphs (a)(1) through (a)(3) above; or
  6. Has been authorized, in writing, to act as agent for the principals of the offeror in certifying that those principals have not participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) above;
  7. As an authorized agent, does certify that the principals of the offeror have not participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) above; and
  8. As an agent, has not personally participated, and will not participate, in any action contrary to subparagraphs (a)(1) through (a)(3) above.
  9. Offeror understands and agrees that:
  10. Violation of this certification will result in immediate disqualification from this solicitation without recourse and may result in disqualification from future solicitations, and
  11. Discovery of any violation after award to the offeror will result in the termination of the award for default.

Acceptability of Contract Terms

Offeror hereby accepts all proposed solicitation and contract terms.

By signature hereon, the Offeror certifies that these statements are accurate, current, and complete.

Name/Title: ______

Signature: ______Date: ______

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