Certificate of Independent
Page 1 of 1
Certificate of Independent Price Determination
Both the school food authority and the Vendor (offeror) shall execute this Certificate of Independent Price
(Name of Vendor)
St. Tammany Parish School Board
(Name of School Food Authority)
(A) By submission of this offer, the offeror certifies and in the case of a joint offer, each party thereto certifies
as to its own organization, that in connection with this procurement:
(1) The prices in this offer have been arrived at independently, without consultation, communication or
agreement, for the purpose of restricting competition, as to any matter relating to such prices with any
other offeror or with any competitor;
(2) Unless otherwise required by law, the prices which have been quoted in this offer have not been
knowingly disclosed by the offeror and will not knowingly be disclosed by the offeror prior to opening in
the case of an advertised procurement, or prior to award in the case of a negotiated procurement,
directly or indirectly to any other offeror or to any competitor; and
(3) No attempt has been made or will be made by the offeror to induce any person or firm to submit or not
to submit, an offer for the purpose of restricting competition.
(B) Each person signing this offer on behalf of the Vendor certifies that:
(1) He or she is the person in the offeror's organization responsible within the organization for the decision
as to the prices being offered herein and has not participated, and will not participate, in any action
contrary to (A)(1) through (A)(3) above; or
(2) He or she is not the person in the offeror's organization responsible within the organization for the
decision as to the prices being offered herein, but that he or she has been authorized in writing to act
as agent for the persons responsible for such decision in certifying that such persons have not
participated and will not participate, in any action contrary to (A)(1) through (A)(3) above, and as their
agent does hereby so certify; and he or she has not participated, and will not participate, in any action
contrary to (A)(1) through (A)(3) above.
To the best of my knowledge, this Vendor, its affiliates, subsidiaries, officers, directors and employees are
not currently under investigation by any governmental agency and have not in the last three years been
convicted or found liable for any act prohibited by State or Federal law in any jurisdiction, involving
conspiracy or collusion with respect to bidding on any public contract, except as follows:
Signature of Vendor’s
In accepting this offer, the SFA certifies that no representative of the SFA has taken any action which may
have jeopardized the independence of the offer referred to above.
Signature of School Food Authority's
Note: Accepting a bidder's offer does not constitute award of the contract.
Page 1 of 2
Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transactions
This certification is required by the regulations implementing Executive Order 12549, Debarment and Suspension, 7 CFR
Part 3017, Section 3017, subpart c- Responsibilities of Participants. The regulations were published in the November 26,
2003, Federal Reqister (pages 66534-66566). Copies of the regulations may be obtained by contacting the Department of
(BEFORE COMPLETING CERTIFICATION, READ ATTACHED NSTRUCTIONS)
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor its principals are
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any Federal department or agency.
(2) Where the prospective lower tier participant is unable to certify any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
Name and Title of Authorized Representative
PR/Award Number or Project Name
Page 2 of 2
INSTRUCTIONS TO BIDDERS FOR COMPLETING CERTIFICATION FORM
NOTE: Each responsive bidder must include this certification statement with it's bid on each contract equaling
or exceeding $25,000 or any contract for audit services regardless of amount.
1. By signing and submitting this form, the prospective lower tier participant is providing the certification
set out on the reverse side in accordance with these instructions.
2. The certification in this clause is a material representation of fact upon which reliance was placed when
this transaction was entered into. If it is later determined that the prospective lower tier participant
knowingly rendered an erroneous certification, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated may pursue available
remedies, including suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice to the person to which this
proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction,
participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used
in this clause, have the meanings set out in the Definitions and Coverage sections of the U. S.
Department of Agriculture regulations 7 CFR 3017 implementing Executive Order 12 549. (Contact the
person to whom this proposal is submitted for assistance in obtaining a copy of those regulations.)
5. The prospective lower tier participant agrees by submitting this form that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a
person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in
this covered transaction, unless authorized by the department or agency with which this transaction
6. The prospective lower tier participant further agrees by submitting this form that it will include this
clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion -
Lower Tier Covered Transaction" without modification in all lower tier covered transactions and in all
solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification that a prospective participant in a
lower tier covered transaction has not been debarred, suspended, ineligible, or voluntarily excluded
from the covered transaction, unless the participant knows that the certification is erroneous. A
participant may decide the method and frequency by which it determines the eligibility of its principals.
Each participant may, but is not required to, check the Nonprocurement List.
Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is not
required to exceed that which is normally possessed by a prudent person in the ordinary course of business
9. Except for transactions authorized under Paragraph 5 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended,
debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other
remedies available to the Federal Government, the department or agency with which this transaction
originated may pursue available remedies, including suspension and/or debarment.
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS, AND COOPERATIVE AGREEMENTS
EXCEEDING $100,000 IN FEDERAL FUNDS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any
person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress,
an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of
any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any
cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal
contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant,
loan, or cooperative agreement, the undersigned shall complete and submit Standard Form - LLL, "Disclosure of
Lobbying Activities," in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for
all subawards (exceeding $100,000 in Federal funds) at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made or
entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by
section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each such failure.
NAME/ADDRESS of VENDOR
TITLE/TITLE of SUBMITTING OFFICIAL
Non-Discrimination Statement: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and
applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and
where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income
is derived from any public assistance program, or protected genetic information in employment or in any program or activity
conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,
found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the
form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or
letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington,
D.C. 20250-9410, by fax (202) 690-7442 or email at firstname.lastname@example.org. Individuals who are deaf, hard of hearing or have
speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).