Microsoft Word - form1111contractoreligiblityverificationall



Contractor Eligibility Verification FormAuthorized Representative of Subrecipient/State:Contract and/or WO:Applicant Name and Address:Activity #:WARNING: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties under 18 U.S.C. 287, 1001 and 31 U.S.C. 3729.Contractor Information?Engineer?Construction/ Demolition Contractor?Environmental Contractor?OtherContractor Name and Address:Phone:City/ State of Licensure/ Certification*:Expiration Date: __/__/___Federal Tax ID Number/Social Security Number:DUNS #: Registration Status*:SAM Registration Period: __/__/____ through __/__/____Insurance Verified*: ? Approved ? Denied ?N/AIns. Coverage Period: __/__/____ through __/__/____*Preparer should attach proof of registration status and insurance coverage for each contract submission. List of Contractor PrincipalsName:Title:Name:Title:Name:Title:Name:Title:Name:Title:Certification of Subrecipient/State RepresentativeI hereby certify the above-referenced Contractor has been reviewed for eligibility and has not been debarred from contracting for federally funded construction projects.Printed Name of Subrecipient/State Representative:Title:Signature of Subrecipient/State Representative:Date:Prior to payment: This form will need to be submitted to the GLO along with Form SF-424D (Assurances – Construction Programs) and a complete insurance binder for the Contractor. The Subrecipient/State Representative is responsible for ensuring the Contractor remains insured throughout the project and/or until their work is complete and satisfactorily agreed uponDisclaimer: The Texas General Land Office has made every effort to ensure the information contained on this form is accurate and in compliance with the most up-to-date CDBG-DR and/or CDBG-MIT federal rules and regulations, as applicable. It should be noted that the Texas General Land Office assumes no liability or responsibility for any error or omission on this form that may result from the interim period between the publication of amended and/or revised federal rules and regulations and the Texas General Land Office's standard review and update schedule. ................
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